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General NPI Number Information
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NPI Number | 1740532084
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Entity Type | Organization
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Legal Business Name | CROWJAM LLC
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Dates
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Enumeration Date | 10/10/2012
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Last Update Date | 10/10/2012
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Provider Practice Location Address
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Address Line | 2249 N RAMPART BLVD
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City | LAS VEGAS
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State | NV
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Zip | 89128-7640
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Country | US
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Telephone | 702-836-3668
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Fax | 702-836-3669
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Provider Business Mailing Address
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Address Line | 2249 N RAMPART BLVD
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City | LAS VEGAS
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State | NV
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Zip | 89128-7640
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Country | US
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Telephone | 702-836-3668
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Fax | 702-836-3669
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JACK D CROWDER
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Credential |
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Telephone | 702-836-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224L00000X
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Taxonomy Name | Pedorthist
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License Number | NV20121582347
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License Number State | NV
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