Provider Demographics
NPI:1861926560
Name:AVEY, MIKE (MS, LAT, ATC, PES)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:AVEY
Suffix:
Gender:M
Credentials:MS, LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23284-9089
Mailing Address - Country:US
Mailing Address - Phone:801-828-2321
Mailing Address - Fax:804-628-0048
Practice Address - Street 1:1300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23284-9089
Practice Address - Country:US
Practice Address - Phone:801-828-2321
Practice Address - Fax:804-628-0048
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260023362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer