Basic Information
| Provider Information | |||||||||
| NPI: | 1942581947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVANCE CARE P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVANCE CARE - NORTH RALEIGH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9276 SCRANTON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921217701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12341 STRICKLAND RD | ||||||||
| Address2: | 102 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198658000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2011 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8586252990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 2010-01420 | NC | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.