Basic Information
| Provider Information | |||||||||
| NPI: | 1033385414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVALOS ANESTHESIA SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 580 BLACK HILLS DR | ||||||||
| Address2: | |||||||||
| City: | CLARKDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863243734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283688118 | ||||||||
| FaxNumber: | 9283688121 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 W MINGUS AVE STE 2A | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286494480 | ||||||||
| FaxNumber: | 9286348118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | AVALOS | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9283688118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AZ18262 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 750316 | 05 | AZ | MEDICAID |