Healthcare Provider Details

I. General information

NPI: 1548681950
Provider Name (Legal Business Name): JMJ3 HERITAGE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2014
Last Update Date: 01/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COMMERCE BLVD
DAVENPORT IA
52807-3495
US

IV. Provider business mailing address

3135 52ND AVENUE CT
BETTENDORF IA
52722-6953
US

V. Phone/Fax

Practice location:
  • Phone: 563-322-1888
  • Fax:
Mailing address:
  • Phone: 563-508-5139
  • Fax: 563-359-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35355
License Number StateIA

VIII. Authorized Official

Name: NAOMI CHELLI
Title or Position: ORGANIZER
Credential: MD
Phone: 563-508-5139