Provider Demographics
NPI:1215179056
Name:AVANTI WELLNESS CENTER FLLLP
Entity Type:Organization
Organization Name:AVANTI WELLNESS CENTER FLLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRAZER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-797-3115
Mailing Address - Street 1:3574 US 1 S
Mailing Address - Street 2:SUITE 113
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6466
Mailing Address - Country:US
Mailing Address - Phone:904-797-3115
Mailing Address - Fax:904-797-2915
Practice Address - Street 1:3574 US 1 S
Practice Address - Street 2:SUITE 113
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6466
Practice Address - Country:US
Practice Address - Phone:904-797-3115
Practice Address - Fax:904-797-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001136300Medicaid
FLDL680AMedicare PIN
FL001136300Medicaid