Provider Demographics
NPI:1992252431
Name:AVANTI-AYUSH, LLC
Entity type:Organization
Organization Name:AVANTI-AYUSH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBODH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-290-2510
Mailing Address - Street 1:1609 WESTWIND DR.
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2515
Mailing Address - Country:US
Mailing Address - Phone:432-290-2510
Mailing Address - Fax:
Practice Address - Street 1:237 W 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2536
Practice Address - Country:US
Practice Address - Phone:432-290-2510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management