Provider Demographics
NPI:1730581760
Name:AVANT-GARDE COMMUNITY COUNSELING CENTER
Entity type:Organization
Organization Name:AVANT-GARDE COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTRAVIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-735-5300
Mailing Address - Street 1:1655 E 6TH ST STE 117A5A
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1732
Mailing Address - Country:US
Mailing Address - Phone:951-735-5300
Mailing Address - Fax:951-735-9335
Practice Address - Street 1:1655 E 6TH ST STE A5A
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1719
Practice Address - Country:US
Practice Address - Phone:951-735-5300
Practice Address - Fax:951-735-9335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA659788OtherCORONA