Provider Demographics
NPI:1740395367
Name:SPACK, JOHN FREDERICK JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FREDERICK
Last Name:SPACK
Suffix:JR
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 1:947 S OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1531
Mailing Address - Country:US
Mailing Address - Phone:614-252-9345
Mailing Address - Fax:
Practice Address - Street 1:947 S OHIO AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-1531
Practice Address - Country:US
Practice Address - Phone:614-252-9345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.004133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist