=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124591276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JANODI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2019
-----------------------------------------------------
Last Update Date | 01/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7807 LONG POINT RD STE 401
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77055-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-658-1017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2047
-----------------------------------------------------
City | WINNIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77665-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | SUZANNE JANACEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 409-658-1017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------