Provider Demographics
NPI:1427510452
Name:JDG PROVIDER SERVICES LLC
Entity type:Organization
Organization Name:JDG PROVIDER SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OBIANWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-372-5024
Mailing Address - Street 1:1419 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2711
Mailing Address - Country:US
Mailing Address - Phone:903-372-5024
Mailing Address - Fax:
Practice Address - Street 1:1419 W 3RD ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2711
Practice Address - Country:US
Practice Address - Phone:903-372-5024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-31
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle