Provider Demographics
NPI:1871126797
Name:AVANZAR WELLNESS LLC
Entity type:Organization
Organization Name:AVANZAR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-908-7882
Mailing Address - Street 1:10096 W FAIRVIEW AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5004
Mailing Address - Country:US
Mailing Address - Phone:208-908-7882
Mailing Address - Fax:208-908-7883
Practice Address - Street 1:10096 W FAIRVIEW AVE STE 160
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5004
Practice Address - Country:US
Practice Address - Phone:208-908-7882
Practice Address - Fax:208-908-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)