Healthcare Provider Details

I. General information

NPI: 1093043275
Provider Name (Legal Business Name): AVANTI-AYUSH,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 WEST 21ST STREED
FORT STOCKTON TX
79735
US

IV. Provider business mailing address

2071 N MAIN ST
FORT STOCKTON TX
79735-3041
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-6922
  • Fax:
Mailing address:
  • Phone: 432-336-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateTX

VIII. Authorized Official

Name: DR. SUBBATH MALLIK
Title or Position: MANAGER OF LLC
Credential: M.D.
Phone: 432-336-0700