Provider Demographics
NPI:1790906170
Name:JACE MEDICAL, INC
Entity Type:Organization
Organization Name:JACE MEDICAL, INC
Other - Org Name:JACE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:JACE
Authorized Official - Suffix:
Authorized Official - Credentials:DOM, LAC, PA-C
Authorized Official - Phone:818-505-8610
Mailing Address - Street 1:10843 MAGNOLIA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-3922
Mailing Address - Country:US
Mailing Address - Phone:818-505-8610
Mailing Address - Fax:
Practice Address - Street 1:10843 MAGNOLIA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3922
Practice Address - Country:US
Practice Address - Phone:818-505-8610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3835171100000X
CAA38484207RE0101X
CA12998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A28630Medicare UPIN