1184918864 NPI number — JENCARE NEIGHBORHOOD MEDICAL NORFOLK, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184918864 NPI number — JENCARE NEIGHBORHOOD MEDICAL NORFOLK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENCARE NEIGHBORHOOD MEDICAL NORFOLK, 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:
1184918864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1395 NW 167TH ST
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:
33169-5710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-628-6117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
549 E BRAMBLETON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23510-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-533-9441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSTON
Authorized Official First Name:
DANIELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
305-628-6117

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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