1104341544 NPI number — JENCARE NEIGHBORHOOD MEDICAL METAIRIE, LLC

Table of content: (NPI 1104341544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104341544 NPI number — JENCARE NEIGHBORHOOD MEDICAL METAIRIE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENCARE NEIGHBORHOOD MEDICAL METAIRIE, 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:
6
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:
1104341544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1395 N.W. 167TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-628-6117
Provider Business Mailing Address Fax Number:
305-831-4408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3530 HOUMA BOULEVARD
Provider Second Line Business Practice Location Address:
JENCARE NEIGHBORHOOD MEDICAL METAIRIE #2
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-628-6117
Provider Business Practice Location Address Fax Number:
305-831-4408
Provider Enumeration Date:
08/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHEN
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
305-628-6117

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PHY.007546-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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