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General NPI Number Information
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NPI Number | 1598442212
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Entity Type | Organization
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Legal Business Name | ADVANCE SUPPORT LLC
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Dates
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Enumeration Date | 07/04/2023
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Last Update Date | 07/05/2023
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Provider Practice Location Address
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Address Line | 972 GOLD FINCH LN
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City | FORNEY
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State | TX
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Zip | 75126-2340
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Country | US
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Telephone | 225-938-6657
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Fax |
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Provider Business Mailing Address
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Address Line | 300 8TH ST SE UNIT 472
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City | ALTOONA
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State | IA
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Zip | 50009-7012
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MOTIA DIOKE ELVIS
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Credential |
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Telephone | 225-938-6657
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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