=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184380230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANT GARDE TOTAL WELLNESS CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2021
-----------------------------------------------------
Last Update Date | 11/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 NEWARK POMPTON TPKE
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07457-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-858-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1151 MACOPIN RD
-----------------------------------------------------
City | WEST MILFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07480-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-615-7317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT WILSON
-----------------------------------------------------
Credential | LMT CLT
-----------------------------------------------------
Telephone | 201-615-7317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------