Provider Demographics
NPI:1174025068
Name:SOULIS, JACK E (CPO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:SOULIS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 BUENA VISTA ST STE 105
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1780
Mailing Address - Country:US
Mailing Address - Phone:626-256-1415
Mailing Address - Fax:626-256-1405
Practice Address - Street 1:931 BUENA VISTA ST STE 105
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1780
Practice Address - Country:US
Practice Address - Phone:626-256-1415
Practice Address - Fax:626-256-1405
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO03980224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist