Healthcare Provider Details

I. General information

NPI: 1437458098
Provider Name (Legal Business Name): JMM VENTURES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 W THUNDERBIRD RD STE 308
GLENDALE AZ
85306
US

IV. Provider business mailing address

5310 W THUNDERBIRD RD STE 308
GLENDALE AZ
85306
US

V. Phone/Fax

Practice location:
  • Phone: 623-412-2229
  • Fax: 602-314-6662
Mailing address:
  • Phone: 623-412-2229
  • Fax: 602-314-6662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number30147
License Number StateAZ

VIII. Authorized Official

Name: TY WITT
Title or Position: PHYSICIAN
Credential: MD
Phone: 623-412-2229