Provider Demographics
NPI:1912779661
Name:AVILA, MATTHEW (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24164 REYES ADOBE WAY
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-1557
Mailing Address - Country:US
Mailing Address - Phone:661-600-2651
Mailing Address - Fax:
Practice Address - Street 1:23206 LYONS AVE STE 105
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2671
Practice Address - Country:US
Practice Address - Phone:661-383-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist