Provider Demographics
NPI:1104099019
Name:STEVEN JOHN AVOLICINO
Entity type:Organization
Organization Name:STEVEN JOHN AVOLICINO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:AVOLICINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-785-6324
Mailing Address - Street 1:2829 DEPOT RD
Mailing Address - Street 2:#4
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-2359
Mailing Address - Country:US
Mailing Address - Phone:510-785-6324
Mailing Address - Fax:
Practice Address - Street 1:2829 DEPOT RD
Practice Address - Street 2:#4
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2359
Practice Address - Country:US
Practice Address - Phone:510-785-6324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ43620ZMedicare PIN