1588967020 NPI number — JX2 LLC

Table of content: DR. MUSTAFA HAKIM GANDHI MD (NPI 1487224887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588967020 NPI number — JX2 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JX2 LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588967020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16820
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83715-6820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-323-9130
Provider Business Mailing Address Fax Number:
208-323-9070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1253 N COLE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-319-0700
Provider Business Practice Location Address Fax Number:
208-321-5069
Provider Enumeration Date:
12/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
208-323-9130

Provider Taxonomy Codes

  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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