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General NPI Number Information
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NPI Number | 1790596682
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Entity Type | Organization
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Legal Business Name | JED BROTHERS LLC
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Dates
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Enumeration Date | 01/18/2025
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Last Update Date | 05/18/2025
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Provider Practice Location Address
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Address Line | 12919 W BELLFORT AVE
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City | SUGAR LAND
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State | TX
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Zip | 77478-1838
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Country | US
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Telephone | 832-810-7105
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Fax | 832-810-7106
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Provider Business Mailing Address
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Address Line | 12919 W BELLFORT AVE
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City | SUGAR LAND
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State | TX
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Zip | 77478-1838
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Country | US
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Telephone | 832-810-7105
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Fax | 832-810-7106
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Authorized Official
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Title or Position | OWNER
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Name | VISMARI VICENTE CORDOVA
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Credential | RN
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Telephone | 713-261-8556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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