Healthcare Provider Details

I. General information

NPI: 1235507781
Provider Name (Legal Business Name): JAI HO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 GEORGIA ST NE STE 400
PALM BAY FL
32907-2537
US

IV. Provider business mailing address

1663 GEORGIA STREET SUITE 400
PALM BAY FL
32907
US

V. Phone/Fax

Practice location:
  • Phone: 321-802-9080
  • Fax: 321-802-5211
Mailing address:
  • Phone: 321-802-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KANTILAL H BHALANI
Title or Position: MD
Credential: MD
Phone: 321-802-9080