Provider Demographics
NPI:1346616190
Name:FAMIGLIO, JACK (DC, ATC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:FAMIGLIO
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9841 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6100
Mailing Address - Country:US
Mailing Address - Phone:954-309-7954
Mailing Address - Fax:
Practice Address - Street 1:9841 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6100
Practice Address - Country:US
Practice Address - Phone:954-437-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13768111N00000X
LAATH.2004582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer