Healthcare Provider Details

I. General information

NPI: 1710325709
Provider Name (Legal Business Name): MEDICAID PROVIDERS NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 N HIAWASSEE RD 428
ORLANDO FL
32818-3319
US

IV. Provider business mailing address

PO BOX 951659
LAKE MARY FL
32795-1659
US

V. Phone/Fax

Practice location:
  • Phone: 407-921-2074
  • Fax: 407-264-8686
Mailing address:
  • Phone: 407-921-2074
  • Fax: 407-264-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberME85696
License Number StateFL

VIII. Authorized Official

Name: JASVENDAR SINGH NANDRA
Title or Position: CEO
Credential: M.D.
Phone: 407-921-2074