Provider Demographics
NPI:1356898357
Name:JAGA MEDICAL GROUP INC
Entity type:Organization
Organization Name:JAGA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARDIENNE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-999-2250
Mailing Address - Street 1:1400 COLORADO BLVD
Mailing Address - Street 2:A
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-2321
Mailing Address - Country:US
Mailing Address - Phone:323-999-2250
Mailing Address - Fax:323-999-2241
Practice Address - Street 1:1400 COLORADO BLVD
Practice Address - Street 2:A
Practice Address - City:EAGLE ROCK
Practice Address - State:CA
Practice Address - Zip Code:90041-2321
Practice Address - Country:US
Practice Address - Phone:323-999-2250
Practice Address - Fax:323-999-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7285208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A7285Medicare Oscar/Certification