Provider Demographics
NPI:1710137369
Name:JAN C JAY DOM PC
Entity Type:Organization
Organization Name:JAN C JAY DOM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAY
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-323-8100
Mailing Address - Street 1:11110 SAN RAFAEL AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2400
Mailing Address - Country:US
Mailing Address - Phone:505-323-8100
Mailing Address - Fax:
Practice Address - Street 1:11110 SAN RAFAEL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2400
Practice Address - Country:US
Practice Address - Phone:505-323-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM637 RX2171100000X
NM1020225100000X
NM3556225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty