Provider Demographics
NPI:1760687271
Name:JERRY KOSAK CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:JERRY KOSAK CHIROPRACTIC, INC.
Other - Org Name:KOSAK CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PERRIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-426-1111
Mailing Address - Street 1:1252 TRAVIS BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4840
Mailing Address - Country:US
Mailing Address - Phone:707-426-1111
Mailing Address - Fax:707-426-2725
Practice Address - Street 1:1252 TRAVIS BLVD STE G
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4840
Practice Address - Country:US
Practice Address - Phone:707-426-1111
Practice Address - Fax:707-426-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25538111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty