Provider Demographics
NPI:1922201284
Name:CACIC, JACK JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:JOSEPH
Last Name:CACIC
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N H ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3701
Mailing Address - Country:US
Mailing Address - Phone:561-547-2210
Mailing Address - Fax:561-547-6689
Practice Address - Street 1:17 N H ST
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3701
Practice Address - Country:US
Practice Address - Phone:561-547-2210
Practice Address - Fax:561-547-6689
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7724111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitation
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54015OtherBCBS
FLE39962Medicare ID - Type Unspecified