=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255757860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVENUE SUPPORTIVE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2014
-----------------------------------------------------
Last Update Date | 03/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5440 N STATE ROAD 7 SUITE 208
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-716-6527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26222
-----------------------------------------------------
City | TAMARAC
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33320-6222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-716-6527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | GOLDIE LOZIER LOUIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-716-6527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 233310
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------