Provider Demographics
NPI:1548681950
Name:JMJ3 HERITAGE, L.L.C.
Entity type:Organization
Organization Name:JMJ3 HERITAGE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-508-5139
Mailing Address - Street 1:3135 52ND AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6953
Mailing Address - Country:US
Mailing Address - Phone:563-508-5139
Mailing Address - Fax:563-359-3828
Practice Address - Street 1:3800 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3495
Practice Address - Country:US
Practice Address - Phone:563-322-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35355208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111692OtherILLINOIS LICENSE
IA35355OtherIOWA LICENSE