Healthcare Provider Details

I. General information

NPI: 1841917622
Provider Name (Legal Business Name): JD GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 DAKOTA AVE APT 57
SANTA CRUZ CA
95060-6615
US

IV. Provider business mailing address

515 GRANBY RD
CHICOPEE MA
01013-3628
US

V. Phone/Fax

Practice location:
  • Phone: 413-330-1366
  • Fax:
Mailing address:
  • Phone: 413-330-1366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK DUNN
Title or Position: OWNER
Credential:
Phone: 413-330-1366