Provider Demographics
NPI:1972509123
Name:ADVANTAGE WELLCARE
Entity Type:Organization
Organization Name:ADVANTAGE WELLCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:386-846-1419
Mailing Address - Street 1:3244 TEALWOOD TER
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3072
Mailing Address - Country:US
Mailing Address - Phone:386-846-1419
Mailing Address - Fax:
Practice Address - Street 1:3244 TEALWOOD TER
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3072
Practice Address - Country:US
Practice Address - Phone:386-846-1419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty