Provider Demographics
NPI:1023897725
Name:AVALOS, GLORIA
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:AVALOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5050
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-5050
Mailing Address - Country:US
Mailing Address - Phone:684-256-7686
Mailing Address - Fax:684-699-6528
Practice Address - Street 1:5050 MOSOOI BUSINESS CENTER
Practice Address - Street 2:SUITE 107
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799
Practice Address - Country:US
Practice Address - Phone:684-699-5058
Practice Address - Fax:684-699-6528
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS1208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist