Provider Demographics
NPI:1710788351
Name:ARCHIE, JACARI TREMAINE SR
Entity type:Individual
Prefix:MR
First Name:JACARI
Middle Name:TREMAINE
Last Name:ARCHIE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16611 GOOSE RIBBON PL
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-2363
Mailing Address - Country:US
Mailing Address - Phone:813-362-1698
Mailing Address - Fax:
Practice Address - Street 1:16611 GOOSE RIBBON PL
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-2363
Practice Address - Country:US
Practice Address - Phone:813-362-1698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA620438813340172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver