Provider Demographics
NPI:1679098750
Name:AVANT-GARDE MEDICAL LLC
Entity Type:Organization
Organization Name:AVANT-GARDE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARIBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRYOUSEFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-238-8646
Mailing Address - Street 1:35 UNITED DR STE 102
Mailing Address - Street 2:
Mailing Address - City:W BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1027
Mailing Address - Country:US
Mailing Address - Phone:1508-238-8646
Mailing Address - Fax:
Practice Address - Street 1:62 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-5634
Practice Address - Country:US
Practice Address - Phone:508-238-8646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty