=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265596340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANTE AT ORMOND BEACH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 03/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 N OLD KINGS RD
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-5118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-677-7955
-----------------------------------------------------
Fax | 386-676-9573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 LAKE ELLENOR DR STE 700
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32809-4643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-216-0101
-----------------------------------------------------
Fax | 407-318-2477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KIMBERLY L. BIEGASIEWICZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-216-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF13960961
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------