Provider Demographics
NPI:1407125016
Name:AVANTE GARDE HEALTH CENTERS, LLC
Entity Type:Organization
Organization Name:AVANTE GARDE HEALTH CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CUNDIFF-ROY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-866-4357
Mailing Address - Street 1:PO BOX 1383
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-1383
Mailing Address - Country:US
Mailing Address - Phone:270-866-4357
Mailing Address - Fax:270-858-4957
Practice Address - Street 1:72 JOE T PETTEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-866-4357
Practice Address - Fax:270-858-4957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care