Healthcare Provider Details

I. General information

NPI: 1609282334
Provider Name (Legal Business Name): J17 PREMIER TRANSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11231 LAKE LANIER DR
RIVERVIEW FL
33569-2935
US

IV. Provider business mailing address

11231 LAKE LANIER DR
RIVERVIEW FL
33569-2935
US

V. Phone/Fax

Practice location:
  • Phone: 727-251-8184
  • Fax:
Mailing address:
  • Phone: 727-251-8184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberW362-433-59-361-0
License Number StateFL

VIII. Authorized Official

Name: MR. JEFFREY MARK WATTERS
Title or Position: PRESIDENT
Credential:
Phone: 727-251-8184