Provider Demographics
NPI:1508175233
Name:AVANTI REHAB GROUP
Entity Type:Organization
Organization Name:AVANTI REHAB GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-626-2416
Mailing Address - Street 1:6079 W MAPLE RD
Mailing Address - Street 2:SUITE 110-B
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2283
Mailing Address - Country:US
Mailing Address - Phone:248-626-2416
Mailing Address - Fax:248-626-3918
Practice Address - Street 1:6079 W MAPLE RD
Practice Address - Street 2:SUITE 110-B
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2283
Practice Address - Country:US
Practice Address - Phone:248-626-2416
Practice Address - Fax:248-626-3918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty