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General NPI Number Information
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NPI Number | 1609282334
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Entity Type | Organization
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Legal Business Name | J17 PREMIER TRANSPORT
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Dates
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Enumeration Date | 07/02/2014
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Last Update Date | 07/02/2014
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Provider Practice Location Address
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Address Line | 11231 LAKE LANIER DR
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City | RIVERVIEW
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State | FL
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Zip | 33569-2935
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Country | US
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Telephone | 727-251-8184
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Fax |
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Provider Business Mailing Address
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Address Line | 11231 LAKE LANIER DR
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City | RIVERVIEW
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State | FL
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Zip | 33569-2935
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Country | US
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Telephone | 727-251-8184
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JEFFREY MARK WATTERS
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Credential |
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Telephone | 727-251-8184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | W362-433-59-361-0
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License Number State | FL
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