1780769711 NPI number — AVANTE AT REIDSVILLE, INC.

Table of content: (NPI 1780769711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780769711 NPI number — AVANTE AT REIDSVILLE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVANTE AT REIDSVILLE, INC.
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:
1780769711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 SHERIDAN STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-3439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-342-1382
Provider Business Mailing Address Fax Number:
336-496-4080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REIDSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27320-4627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-342-1382
Provider Business Practice Location Address Fax Number:
336-616-0868
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-987-7180

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  NH0293 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NH0293 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3435227 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3436230 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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