Provider Demographics
NPI:1851336994
Name:JCL GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:JCL GASTROENTEROLOGY, LLC
Other - Org Name:NORTH VALLEY GASTROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-485-7460
Mailing Address - Street 1:PO BOX 9907
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-0907
Mailing Address - Country:US
Mailing Address - Phone:602-485-7475
Mailing Address - Fax:602-485-7492
Practice Address - Street 1:18404 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1511
Practice Address - Country:US
Practice Address - Phone:602-485-7475
Practice Address - Fax:602-485-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ108540Medicare PIN