Provider Demographics
NPI:1518526508
Name:AVANTGARDE AESTHETIC AND WELLNESS MEDICAL CENTER
Entity Type:Organization
Organization Name:AVANTGARDE AESTHETIC AND WELLNESS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:541-238-2108
Mailing Address - Street 1:1000 WILLAGILLESPIE RD STE 175
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7106
Mailing Address - Country:US
Mailing Address - Phone:541-514-1727
Mailing Address - Fax:
Practice Address - Street 1:1000 WILLAGILLESPIE RD STE 175
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7106
Practice Address - Country:US
Practice Address - Phone:541-514-1727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty