Basic Information
| Provider Information | |||||||||
| NPI: | 1104341544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENCARE NEIGHBORHOOD MEDICAL METAIRIE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JENCARE NEIGHBORHOOD MEDICAL METAIRIE#2 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 N.W. 167TH STREET | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | 3058314408 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 HOUMA BOULEVARD | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL METAIRIE #2 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | 3058314408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2017 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3056286117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PMR LA HOLDING, LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 333600000X | PHY.007546-IR | LA | Y | Suppliers | Pharmacy |
No ID Information.