Provider Demographics
NPI:1245248400
Name:AVILA, ROBERT JOSEPH (DC, CCST, CCCN)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:AVILA
Suffix:
Gender:M
Credentials:DC, CCST, CCCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CO4867111NN0400X, 111NN1001X, 111NP0017X, 111NR0200X, 111NS0005X, 111NX0100X, 111NX0800X, 111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0200XChiropractic ProvidersChiropractorRadiology
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4867OtherCOLORADO LICENSE UPIN
COCOA106967OtherMEDICARE PTAN DR AVILA
CO841603517OtherTAX I.D.
CO1245248400OtherNPI DR AVILA
CO1821363557OtherGROUP NPI
CO1295797413OtherNPI DR WILSON
COA106966OtherGROUP PTAN
COCOA107185OtherMEDICARE PTAN DR. WILSON
CO841603517OtherTAX I.D.
COA106966OtherGROUP PTAN