Provider Demographics
NPI:1174833818
Name:AVANT, MASSIE ANDRE JR (RS)
Entity type:Individual
Prefix:MR
First Name:MASSIE
Middle Name:ANDRE
Last Name:AVANT
Suffix:JR
Gender:M
Credentials:RS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 N. MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:951-849-8812
Mailing Address - Fax:
Practice Address - Street 1:245 N. MURRAY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS6036174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator