Provider Demographics
NPI:1861403974
Name:AVANTI WELLNESS CENTER INC
Entity type:Organization
Organization Name:AVANTI WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-824-7597
Mailing Address - Street 1:165 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4101
Mailing Address - Country:US
Mailing Address - Phone:904-824-7597
Mailing Address - Fax:904-824-7598
Practice Address - Street 1:165 SOUTHPARK BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4101
Practice Address - Country:US
Practice Address - Phone:904-824-7597
Practice Address - Fax:904-824-7598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLPY7098103TC0700X
FLSW51511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC7024OtherMEDICAL LICENSE NUMBER