Provider Demographics
NPI:1922694710
Name:AVALA PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:AVALA PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-801-6258
Mailing Address - Street 1:67252 INDUSTRY LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8704
Mailing Address - Country:US
Mailing Address - Phone:985-888-1182
Mailing Address - Fax:
Practice Address - Street 1:1200 PINNACLE PKWY
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-9167
Practice Address - Country:US
Practice Address - Phone:985-674-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRWAY MEDICAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain