Basic Information
| Provider Information | |||||||||
| NPI: | 1184918864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JENCARE NEIGHBORHOOD MEDICAL NORFOLK, LLC | ||||||||
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| OtherOrganizationName: | JENCARE NEIGHBORHOOD MEDICAL - NORFOLK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20801 NW 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331692103 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 549 E BRAMBLETON AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235102915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575339441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTER | ||||||||
| AuthorizedOfficialTelephone: | 3056986500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.