Provider Demographics
NPI:1972077840
Name:XANADU HEALTHCARE, LLC
Entity Type:Organization
Organization Name:XANADU HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:423-620-0575
Mailing Address - Street 1:2320 DALEBROOK CT
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-1338
Mailing Address - Country:US
Mailing Address - Phone:423-620-0575
Mailing Address - Fax:
Practice Address - Street 1:2320 DALEBROOK CT
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206-1338
Practice Address - Country:US
Practice Address - Phone:423-620-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty