Provider Demographics
NPI:1437531308
Name:JSK JSN LLC
Entity Type:Organization
Organization Name:JSK JSN LLC
Other - Org Name:AVALON MEDICAL WALK IN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAUSHIKKUMAR
Authorized Official - Middle Name:K
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-289-1951
Mailing Address - Street 1:14807 E COLONIAL DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-5122
Mailing Address - Country:US
Mailing Address - Phone:321-289-1951
Mailing Address - Fax:
Practice Address - Street 1:14807 E COLONIAL DR
Practice Address - Street 2:SUITE 112
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-5122
Practice Address - Country:US
Practice Address - Phone:407-250-6742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17451100Medicaid
FL17451100Medicaid