MEDICARE: JERITY ENTERPRISES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	07625378E	AZ

General Provider Information

NPI Number	:	1063682524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERITY ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	1063 N OPAL
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-2275
Country	:	US
Telephone Number	:	602-308-8383
Fax Number	:	480-699-6413

Provider Business Practice Location Address
First Line	:	14362 N FRANK LLOYD WRIGHT BLVD
Second Line	:	SUITE B109
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85260-8846
Country	:	US
Telephone Number	:	602-308-8383
Fax Number	:	480-699-6413

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. JERRY DON SANSTEAD JR.
Credential	:
Telephone Number	:	602-308-8383

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	05/06/2008

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