=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073997953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMARRS HANDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3090 BASSETT HEIGHTS ROAD EXT
-----------------------------------------------------
City | BASSETT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24055-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-252-1043
-----------------------------------------------------
Fax | 276-421-2300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3090 BASSETT HGHTS RD
-----------------------------------------------------
City | BASSETT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24055-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-252-1043
-----------------------------------------------------
Fax | 276-421-2300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SERVICE FACILATOR
-----------------------------------------------------
Name | DORTHEA MORNET KIRBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-252-1043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 45-0674833
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------