Healthcare Provider Details

I. General information

NPI: 1770189706
Provider Name (Legal Business Name): JMDO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2020
Last Update Date: 12/06/2020
Certification Date: 12/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

866 CY AVE
CASPER WY
82601-4162
US

IV. Provider business mailing address

1510 S CEDAR ST
CASPER WY
82601-4141
US

V. Phone/Fax

Practice location:
  • Phone: 307-200-9669
  • Fax: 814-200-0084
Mailing address:
  • Phone: 307-200-9669
  • Fax: 814-200-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSE MILLER
Title or Position: OWNER
Credential: DO
Phone: 307-200-9669