Provider Demographics
NPI:1104341544
Name:JENCARE NEIGHBORHOOD MEDICAL METAIRIE, LLC
Entity type:Organization
Organization Name:JENCARE NEIGHBORHOOD MEDICAL METAIRIE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-628-6117
Mailing Address - Street 1:1395 N.W. 167TH STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:305-831-4408
Practice Address - Street 1:3530 HOUMA BOULEVARD
Practice Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL METAIRIE #2
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:305-628-6117
Practice Address - Fax:305-831-4408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PMR LA HOLDING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-07
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
LAPHY.007546-IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty