Provider Demographics
NPI:1700803632
Name:ADVANCED HEALTHCARE SOLUTIONS LLC
Entity type:Organization
Organization Name:ADVANCED HEALTHCARE SOLUTIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:VAWDREY
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:208-478-7422
Mailing Address - Street 1:495 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4531
Mailing Address - Country:US
Mailing Address - Phone:208-478-7422
Mailing Address - Fax:208-478-1515
Practice Address - Street 1:495 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4531
Practice Address - Country:US
Practice Address - Phone:208-478-7422
Practice Address - Fax:208-478-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1369069Medicare PIN