Provider Demographics
NPI:1831250190
Name:PAUL DANTE JACOY, DC INC.
Entity type:Organization
Organization Name:PAUL DANTE JACOY, DC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DANTE
Authorized Official - Last Name:JACOY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-585-1616
Mailing Address - Street 1:610 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1220
Mailing Address - Country:US
Mailing Address - Phone:626-585-1616
Mailing Address - Fax:626-585-1686
Practice Address - Street 1:610 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1220
Practice Address - Country:US
Practice Address - Phone:626-585-1616
Practice Address - Fax:626-585-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC783AMedicare PIN