Provider Demographics
NPI:1083161830
Name:JACKLAB, INC
Entity Type:Organization
Organization Name:JACKLAB, INC
Other - Org Name:JOHN MCNULTY, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-516-4836
Mailing Address - Street 1:6369 MILL ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-1406
Mailing Address - Country:US
Mailing Address - Phone:845-516-4836
Mailing Address - Fax:845-516-4233
Practice Address - Street 1:6369 MILL ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-1406
Practice Address - Country:US
Practice Address - Phone:845-516-4836
Practice Address - Fax:845-516-4233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206911207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty