MEDICARE: CROWJAM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224L00000X	Pedorthist	NV20121582347	NV

General Provider Information

NPI Number	:	1740532084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWJAM LLC

Provider Business Mailing Address
First Line	:	2249 N RAMPART BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7640
Country	:	US
Telephone Number	:	702-836-3668
Fax Number	:	702-836-3669

Provider Business Practice Location Address
First Line	:	2249 N RAMPART BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7640
Country	:	US
Telephone Number	:	702-836-3668
Fax Number	:	702-836-3669

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JACK D CROWDER
Credential	:
Telephone Number	:	702-836-3668

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	10/10/2012

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Directions to “CROWJAM LLC ” Practice Location

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