Provider Demographics
NPI:1740690445
Name:J & KWAK COMPANY, LLC
Entity type:Organization
Organization Name:J & KWAK COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TJ
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-634-0224
Mailing Address - Street 1:1790 RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-3629
Mailing Address - Country:US
Mailing Address - Phone:347-634-0224
Mailing Address - Fax:718-991-2662
Practice Address - Street 1:1790 RANDALL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-3629
Practice Address - Country:US
Practice Address - Phone:347-634-0224
Practice Address - Fax:718-991-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051024261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental