Provider Demographics
NPI:1083109458
Name:JUPITER TAJ INVESTMENT GROUP, LLC
Entity Type:Organization
Organization Name:JUPITER TAJ INVESTMENT GROUP, LLC
Other - Org Name:JUPITER TAJ INVESTMENT GROUP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:BERKOS
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:561-281-2105
Mailing Address - Street 1:731 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-2218
Mailing Address - Country:US
Mailing Address - Phone:561-281-2105
Mailing Address - Fax:561-281-2105
Practice Address - Street 1:3335 BURNS RD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4311
Practice Address - Country:US
Practice Address - Phone:561-529-8059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder