Provider Demographics
NPI:1831493063
Name:JACK, TODDY (CEO)
Entity Type:Individual
Prefix:
First Name:TODDY
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ROAD TO SIXFLAGS STREET
Mailing Address - Street 2:144
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012
Mailing Address - Country:US
Mailing Address - Phone:817-461-0034
Mailing Address - Fax:817-461-0035
Practice Address - Street 1:801 ROAD TO SIXFLAGS STREET
Practice Address - Street 2:144
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012
Practice Address - Country:US
Practice Address - Phone:817-461-0034
Practice Address - Fax:817-461-0035
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4765290876163WX0200X
TX345782195171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No163WX0200XNursing Service ProvidersRegistered NurseOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6787445908OtherMULTIPLE LICENCE
TX6787445908OtherMULTIPLE LICENCE