Basic Information
| Provider Information | |||||||||
| NPI: | 1689823387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAYCO ANESTHESIA SERVICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD STE 440 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
| FaxNumber: | 3104729582 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 ULMERTON RD | ||||||||
| Address2: | STE. 27 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337622282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275920991 | ||||||||
| FaxNumber: | 7272094606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2008 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | JAWANZA | ||||||||
| AuthorizedOfficialFirstName: | JABARI | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9419218122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.