Provider Demographics
NPI:1710723994
Name:JEVANTRAD NETWORK LLC
Entity type:Organization
Organization Name:JEVANTRAD NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARION
Authorized Official - Middle Name:
Authorized Official - Last Name:DDAMULIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:401-261-9519
Mailing Address - Street 1:9558 W RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-4554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9558 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-4554
Practice Address - Country:US
Practice Address - Phone:401-261-9519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service