Provider Demographics
NPI:1821208992
Name:AVALON MEDICAL ASSOCIATES INCORPORATED
Entity Type:Organization
Organization Name:AVALON MEDICAL ASSOCIATES INCORPORATED
Other - Org Name:FAMILY HEALING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:XAVIER
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-574-9547
Mailing Address - Street 1:332 OLD NEWPORT BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4149
Mailing Address - Country:US
Mailing Address - Phone:949-574-9547
Mailing Address - Fax:949-574-9523
Practice Address - Street 1:332 OLD NEWPORT BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4149
Practice Address - Country:US
Practice Address - Phone:949-574-9547
Practice Address - Fax:949-574-9523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41718174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29441Medicare UPIN