=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699414680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMH ENTERPRISE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2022
-----------------------------------------------------
Last Update Date | 05/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13241 BARTRAM PARK BLVD UNIT 2009
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-417-5337
-----------------------------------------------------
Fax | 904-930-4222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13241 BARTRAM PARK BLVD UNIT 2009
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-5223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-417-5337
-----------------------------------------------------
Fax | 904-930-4222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FARID AHMED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 833-417-5337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------