Healthcare Provider Details

I. General information

NPI: 1457847212
Provider Name (Legal Business Name): GOMITJAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12195 SE 135TH AVE
OCKLAWAHA FL
32179-5203
US

IV. Provider business mailing address

1019 SAINT IVES CT
MOUNT DORA FL
32757-9129
US

V. Phone/Fax

Practice location:
  • Phone: 352-288-0226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: KHURRAM MIR
Title or Position: PRESIDENT
Credential:
Phone: 407-723-9088