Basic Information
| Provider Information | |||||||||
| NPI: | 1558444505 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVANTE AT ROANOKE, INC. | ||||||||
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| 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: | 324 KING GEORGE AVE SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240165213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403458139 | ||||||||
| FaxNumber: | 5403456421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | DICKMANN | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9549877180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2491 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4960734 | 05 | VA | MEDICAID | 4951565 | 05 | VA | MEDICAID |