Healthcare Provider Details

I. General information

NPI: 1871126797
Provider Name (Legal Business Name): AVANZAR WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10096 W FAIRVIEW AVE STE 160
BOISE ID
83704-5004
US

IV. Provider business mailing address

10096 W FAIRVIEW AVE STE 160
BOISE ID
83704-5004
US

V. Phone/Fax

Practice location:
  • Phone: 208-908-7882
  • Fax: 208-908-7883
Mailing address:
  • Phone: 208-908-7882
  • Fax: 208-908-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JOSE CARBAJAL
Title or Position: DIRECTOR OF OPERATIONS
Credential: MS
Phone: 208-908-7882