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General NPI Number Information
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NPI Number | 1467316042
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Entity Type | Organization
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Legal Business Name | THE GOOD SAMARITAN JATI CLINIC
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Dates
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Enumeration Date | 12/09/2025
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 15182 N 75TH AVE, STE180
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City | PEORIA
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State | AZ
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Zip | 85381
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Country | US
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Telephone | 480-712-7108
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Fax | 480-300-5840
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Provider Business Mailing Address
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Address Line | 15182 N 75TH AVE STE 180
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City | PEORIA
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State | AZ
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Zip | 85381-4722
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Country | US
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Telephone | 480-300-5798
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Fax | 480-300-5840
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Authorized Official
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Title or Position | OWNER
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Name | MR. JACKSON TARAVINE
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Credential | PA
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Telephone | 786-865-3586
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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