Healthcare Provider Details

I. General information

NPI: 1518410547
Provider Name (Legal Business Name): JUBILEE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36711 AMERICAN WAY SUITE A
AVON OH
44011-4062
US

IV. Provider business mailing address

36711 AMERICAN WAY SUITE A
AVON OH
44011-4062
US

V. Phone/Fax

Practice location:
  • Phone: 440-653-6091
  • Fax: 440-653-8089
Mailing address:
  • Phone: 440-653-6091
  • Fax: 440-653-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. FRED DEGRANDIS
Title or Position: PRESIDENT
Credential:
Phone: 216-312-5059