Provider Demographics
NPI:1932434438
Name:AVAOCADO MEDICAL GROUP
Entity Type:Organization
Organization Name:AVAOCADO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:8941 ATLANTA AVE # 522
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-7121
Mailing Address - Country:US
Mailing Address - Phone:714-299-2666
Mailing Address - Fax:949-438-3868
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:702
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-720-9266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-16
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50213332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site