Provider Demographics
NPI:1871862599
Name:AVESIS, LLC
Entity Type:Organization
Organization Name:AVESIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGULATORY LICENSE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-356-4244
Mailing Address - Street 1:1275 W WASHINGTON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85288-1859
Mailing Address - Country:US
Mailing Address - Phone:800-522-0258
Mailing Address - Fax:
Practice Address - Street 1:1275 W WASHINGTON ST STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-1859
Practice Address - Country:US
Practice Address - Phone:800-522-0258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization