Healthcare Provider Details

I. General information

NPI: 1710375662
Provider Name (Legal Business Name): JIVANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4927 AUBURN AVE STE 200
BETHESDA MD
20814-2641
US

IV. Provider business mailing address

8347 CHERRY LN
LAUREL MD
20707-4828
US

V. Phone/Fax

Practice location:
  • Phone: 301-951-3606
  • Fax: 240-215-3171
Mailing address:
  • Phone: 410-529-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GEZZER ORTEGA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 301-951-3606