Healthcare Provider Details

I. General information

NPI: 1619710522
Provider Name (Legal Business Name): JANUS JAIN MERCHANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 200A
COLUMBIA SC
29203-6859
US

IV. Provider business mailing address

6821 WHITE SHELL CIR
LAS VEGAS NV
89108-5021
US

V. Phone/Fax

Practice location:
  • Phone: 802-434-6155
  • Fax:
Mailing address:
  • Phone: 702-350-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number850216
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL97058
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number850216
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: