Provider Demographics
NPI:1053644112
Name:BETTY A JETAWO
Entity Type:Organization
Organization Name:BETTY A JETAWO
Other - Org Name:GOLDEN HAWK MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:JETAWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-641-8494
Mailing Address - Street 1:PO BOX 494462
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75049-4462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4402 BROADWAY BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-8263
Practice Address - Country:US
Practice Address - Phone:214-641-8494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies