Healthcare Provider Details

I. General information

NPI: 1457635773
Provider Name (Legal Business Name): JPMMH ENTERPRISES OF VERO BEACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 37TH ST SUITE B-107
VERO BEACH FL
32960-4873
US

IV. Provider business mailing address

777 37TH ST SUITE B-107
VERO BEACH FL
32960-4873
US

V. Phone/Fax

Practice location:
  • Phone: 772-226-5026
  • Fax: 772-226-7682
Mailing address:
  • Phone: 772-226-5026
  • Fax: 772-226-7682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101301
License Number StateFL

VIII. Authorized Official

Name: MR. LARRY JAMES
Title or Position: CO-OWNER
Credential: P.A.-C
Phone: 772-226-5026