Basic Information
Provider Information | |||||||||
NPI: | 1174608194 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVANTE AT CONCORD, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4000 HOLLYWOOD BLVD | ||||||||
Address2: | SUITE 540 NORTH | ||||||||
City: | HOLLYWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 330216751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549877180 | ||||||||
FaxNumber: | 9549895287 | ||||||||
Practice Location | |||||||||
Address1: | 515 LAKE CONCORD RD NE | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280252925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7047844494 | ||||||||
FaxNumber: | 7047849669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 06/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DICKMANN | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9859877180 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0179 | NC | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X | NH0179 | NC | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 3416003 | 05 | NC |   | MEDICAID | 3415130 | 05 | NC |   | MEDICAID |