Basic Information
| Provider Information | |||||||||
| NPI: | 1912621459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVILES | ||||||||
| FirstName: | JOVANNY | ||||||||
| MiddleName: | N/A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10301 GRAND CENTRAL AVE APT 529 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211174075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455450622 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4 PARK CENTER CT STE 102 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103778900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2022 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A5725 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.