Provider Demographics
NPI:1992343834
Name:AVANTE RECOVERY CENTER, LLC
Entity type:Organization
Organization Name:AVANTE RECOVERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-550-0750
Mailing Address - Street 1:9 E EXCHANGE PL STE 600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2774
Mailing Address - Country:US
Mailing Address - Phone:801-550-0750
Mailing Address - Fax:
Practice Address - Street 1:848 E 1475 N
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3568
Practice Address - Country:US
Practice Address - Phone:801-550-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVANTE RECOVERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-11
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT84459OtherDEPARTMENT OF HUMAN SERVICES - DAY TREATMENT LICENSE
UT82232OtherDEPARTMENT OF HUMAN SERVICES - RESIDENTIAL LICENSE
UT84460OtherDEPARTMENT OF HUMAN SERVICES - OUTPATIENT LICENSE
UT84458OtherDEPARTMENT OF HUMAN SERVICES - DETOXIFICATION LICENSE