Provider Demographics
NPI:1306437199
Name:DR JAKE MD LLC
Entity type:Organization
Organization Name:DR JAKE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-351-2566
Mailing Address - Street 1:2484 CARING WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5306
Mailing Address - Country:US
Mailing Address - Phone:701-351-2566
Mailing Address - Fax:
Practice Address - Street 1:2484 CARING WAY UNIT A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5306
Practice Address - Country:US
Practice Address - Phone:941-979-5154
Practice Address - Fax:941-235-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care