Provider Demographics
NPI:1376544114
Name:JACK QUEREQUINCIA
Entity Type:Organization
Organization Name:JACK QUEREQUINCIA
Other - Org Name:SIMI MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:QUEREQUINCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-581-5905
Mailing Address - Street 1:2375 SYCAMORE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2787
Mailing Address - Country:US
Mailing Address - Phone:805-581-5905
Mailing Address - Fax:805-581-1478
Practice Address - Street 1:2375 SYCAMORE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2787
Practice Address - Country:US
Practice Address - Phone:805-581-5905
Practice Address - Fax:805-581-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4291050001Medicare ID - Type Unspecified