Healthcare Provider Details

I. General information

NPI: 1922392497
Provider Name (Legal Business Name): JENCARE NEIGHBORHOOD MEDICAL SHOCKOE BOTTOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 E BROAD ST
RICHMOND VA
23223-6930
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 804-644-0059
  • Fax:
Mailing address:
  • Phone: 305-628-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARY CHEN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 305-831-4722