Provider Demographics
NPI:1619519840
Name:PLATINUM VENTURE GROUP LLC
Entity Type:Organization
Organization Name:PLATINUM VENTURE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-214-9918
Mailing Address - Street 1:848 E WOODOAK LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6370
Mailing Address - Country:US
Mailing Address - Phone:623-248-4275
Mailing Address - Fax:623-248-4273
Practice Address - Street 1:7071 N 138TH AVE BLDG 1540
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-2006
Practice Address - Country:US
Practice Address - Phone:623-248-4275
Practice Address - Fax:623-248-4273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies