Provider Demographics
NPI:1821363557
Name:AVILA INTEGRATIVE MEDICINE, INC.
Entity Type:Organization
Organization Name:AVILA INTEGRATIVE MEDICINE, INC.
Other - Org Name:AVILA INTEGRATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCST, CCCN
Authorized Official - Phone:719-565-1276
Mailing Address - Street 1:3960 IVYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2567
Mailing Address - Country:US
Mailing Address - Phone:719-565-1276
Mailing Address - Fax:719-565-2313
Practice Address - Street 1:3960 IVYWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2567
Practice Address - Country:US
Practice Address - Phone:719-565-1276
Practice Address - Fax:719-565-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4867111N00000X
CO31499208VP0000X
CO7987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty