Healthcare Provider Details

I. General information

NPI: 1649992777
Provider Name (Legal Business Name): GJA INVESTMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 SW 106TH TER
DAVIE FL
33328-2154
US

IV. Provider business mailing address

4241 SW 106TH TER
DAVIE FL
33328-2154
US

V. Phone/Fax

Practice location:
  • Phone: 954-251-1869
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TATYANA CHARNY
Title or Position: COO
Credential:
Phone: 818-304-1628