Provider Demographics
NPI:1861056962
Name:AVILA, BLANCA GLORIA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:GLORIA
Last Name:AVILA
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 1:930 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:GUSTINE
Mailing Address - State:CA
Mailing Address - Zip Code:95322-1819
Mailing Address - Country:US
Mailing Address - Phone:408-655-1391
Mailing Address - Fax:
Practice Address - Street 1:1522 HILLSDALE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-1037
Practice Address - Country:US
Practice Address - Phone:408-655-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3718441432251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health