MEDICARE: JIVANA 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1710375662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIVANA LLC

Provider Business Mailing Address
First Line	:	8347 CHERRY LN
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-4828
Country	:	US
Telephone Number	:	410-529-7880
Fax Number	:

Provider Business Practice Location Address
First Line	:	4927 AUBURN AVE STE 200
Second Line	:
City	:	BETHESDA
State	:	MD
Zip	:	20814-2641
Country	:	US
Telephone Number	:	301-951-3606
Fax Number	:	240-215-3171

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. GEZZER ORTEGA
Credential	:	MD
Telephone Number	:	301-951-3606

Provider Enumeration Date	:	12/30/2014
Last Update Date	:	09/08/2022

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Directions to “JIVANA LLC ” Practice Location

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