Provider Demographics
NPI:1710325709
Name:MEDICAID PROVIDERS NETWORK, LLC
Entity Type:Organization
Organization Name:MEDICAID PROVIDERS NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASVENDAR
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:NANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-921-2074
Mailing Address - Street 1:PO BOX 951659
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-1659
Mailing Address - Country:US
Mailing Address - Phone:407-921-2074
Mailing Address - Fax:407-264-8686
Practice Address - Street 1:2840 N HIAWASSEE RD
Practice Address - Street 2:428
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3319
Practice Address - Country:US
Practice Address - Phone:407-921-2074
Practice Address - Fax:407-264-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85696302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization