Basic Information
| Provider Information | |||||||||
| NPI: | 1255416293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVANTE AT WILKESBORO, 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: | 1000 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286972732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368384141 | ||||||||
| FaxNumber: | 3368384019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICKMANN | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9549877180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0451 | NC | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH0451 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3416464 | 05 | NC | MEDICAID | 3425133 | 05 | NC | MEDICAID |