Provider Demographics
NPI:1578792487
Name:PTACK, JOHN S
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:PTACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92195-3216
Mailing Address - Country:US
Mailing Address - Phone:619-517-2327
Mailing Address - Fax:
Practice Address - Street 1:2049 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-4221
Practice Address - Country:US
Practice Address - Phone:619-465-7303
Practice Address - Fax:619-644-2503
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)