Provider Demographics
NPI:1487081360
Name:NANAMAE LLC
Entity type:Organization
Organization Name:NANAMAE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYMOND
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-586-1536
Mailing Address - Street 1:1401 E RUSK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-3400
Mailing Address - Country:US
Mailing Address - Phone:903-586-1536
Mailing Address - Fax:
Practice Address - Street 1:1401 E RUSK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-3400
Practice Address - Country:US
Practice Address - Phone:903-586-1536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center