Provider Demographics
NPI:1164830428
Name:J&J ANESTHESIA, LLC
Entity Type:Organization
Organization Name:J&J ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKIDES
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:843-424-3474
Mailing Address - Street 1:1690 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8979
Mailing Address - Country:US
Mailing Address - Phone:888-836-7015
Mailing Address - Fax:
Practice Address - Street 1:1 WELLNESS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2871
Practice Address - Country:US
Practice Address - Phone:803-732-8632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty