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General NPI Number Information
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NPI Number | 1871126797
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Entity Type | Organization
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Legal Business Name | AVANZAR WELLNESS LLC
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Dates
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Enumeration Date | 02/19/2020
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 10096 W FAIRVIEW AVE STE 160
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City | BOISE
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State | ID
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Zip | 83704-5004
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Country | US
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Telephone | 208-908-7882
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Fax | 208-908-7883
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Provider Business Mailing Address
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Address Line | 10096 W FAIRVIEW AVE STE 160
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City | BOISE
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State | ID
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Zip | 83704-5004
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Country | US
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Telephone | 208-908-7882
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Fax | 208-908-7883
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | JOSE CARBAJAL
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Credential | MS
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Telephone | 208-908-7882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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