1992343834 NPI number — AVANTE RECOVERY CENTER, LLC

Table of content: (NPI 1992343834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992343834 NPI number — AVANTE RECOVERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVANTE RECOVERY CENTER, LLC
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:
AVANTE TREATMENT CENTER, LLC
Provider Other Organization Name Type Code:
4
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:
1992343834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 E EXCHANGE PL STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84111-2774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-550-0750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
848 E 1475 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHI
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84043-3568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-550-0750
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2019

Additional Information

Authorized Official

Authorized Official Last Name:
NIELSON
Authorized Official First Name:
DWAYNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING OWNER
Authorized Official Telephone Number:
801-550-0750

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84459 . This is a "DEPARTMENT OF HUMAN SERVICES - DAY TREATMENT LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 82232 . This is a "DEPARTMENT OF HUMAN SERVICES - RESIDENTIAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 84460 . This is a "DEPARTMENT OF HUMAN SERVICES - OUTPATIENT LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 84458 . This is a "DEPARTMENT OF HUMAN SERVICES - DETOXIFICATION LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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