Provider Demographics
NPI:1982903720
Name:JACKRABBIT SHOES AND ORTHOTICS, INC.
Entity Type:Organization
Organization Name:JACKRABBIT SHOES AND ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-751-1630
Mailing Address - Street 1:4576 E 2ND ST
Mailing Address - Street 2:H
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-1046
Mailing Address - Country:US
Mailing Address - Phone:707-751-1630
Mailing Address - Fax:925-226-3184
Practice Address - Street 1:4576 E 2ND ST
Practice Address - Street 2:H
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-1046
Practice Address - Country:US
Practice Address - Phone:707-751-1630
Practice Address - Fax:925-226-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPED 2916335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier