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General NPI Number Information
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NPI Number | 1093033003
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Entity Type | Organization
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Legal Business Name | AVANTI WELLNESS CENTER FLLLP
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Dates
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Enumeration Date | 05/14/2010
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Last Update Date | 02/28/2011
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Provider Practice Location Address
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Address Line | 3574 US 1 S SUITE 113
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6466
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Country | US
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Telephone | 904-797-3115
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Fax | 904-797-2915
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Provider Business Mailing Address
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Address Line | 3574 US 1 S SUITE 113
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6466
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Country | US
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Telephone | 904-797-3115
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Fax | 904-797-2915
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MRS. RANDI B BRAZER
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Credential | LCSW
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Telephone | 904-797-3115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 77644
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License Number State | FL
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