1518526508 NPI number — AVANTGARDE AESTHETIC AND WELLNESS MEDICAL CENTER

Table of content: (NPI 1518526508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518526508 NPI number — AVANTGARDE AESTHETIC AND WELLNESS MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVANTGARDE AESTHETIC AND WELLNESS MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518526508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 WILLAGILLESPIE RD STE 175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-7106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-514-1727
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 WILLAGILLESPIE RD STE 175
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-7106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-514-1727
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
JELENA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
541-238-2108

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com