Provider Demographics
NPI:1528200029
Name:AVANTI WELLNESS CENTER FLLLP
Entity type:Organization
Organization Name:AVANTI WELLNESS CENTER FLLLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRAZER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-797-3115
Mailing Address - Street 1:3574 US 1 S
Mailing Address - Street 2:SUITE 113
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6466
Mailing Address - Country:US
Mailing Address - Phone:904-797-3115
Mailing Address - Fax:904-797-2915
Practice Address - Street 1:3574 US 1 S
Practice Address - Street 2:SUITE 113
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6466
Practice Address - Country:US
Practice Address - Phone:904-797-3115
Practice Address - Fax:904-797-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
FLHCC7499261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001136302Medicaid