Provider Demographics
NPI:1366724825
Name:AVALON MEDICAL SPA
Entity type:Organization
Organization Name:AVALON MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:THORNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:774-202-7049
Mailing Address - Street 1:651 ORCHARD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02744-1052
Mailing Address - Country:US
Mailing Address - Phone:774-202-7049
Mailing Address - Fax:774-202-2839
Practice Address - Street 1:651 ORCHARD ST STE 202
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02744-1052
Practice Address - Country:US
Practice Address - Phone:774-202-7049
Practice Address - Fax:774-202-2839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1138975261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service