Provider Demographics
NPI:1164935664
Name:AVANT-GARDE LLC
Entity Type:Organization
Organization Name:AVANT-GARDE LLC
Other - Org Name:MINUS 250 DEGREES CRYOTHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:LARSON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-548-3417
Mailing Address - Street 1:293 E 930 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5001
Mailing Address - Country:US
Mailing Address - Phone:801-548-3417
Mailing Address - Fax:
Practice Address - Street 1:293 E 930 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5001
Practice Address - Country:US
Practice Address - Phone:801-548-3417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty