Healthcare Provider Details

I. General information

NPI: 1700611563
Provider Name (Legal Business Name): JACK OF ALL STIXX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CENTERVIEW DR STE 64
GREENSBORO NC
27407-3708
US

IV. Provider business mailing address

555 WHISTLING SWAN DR
GREENSBORO NC
27455-1535
US

V. Phone/Fax

Practice location:
  • Phone: 336-303-0587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DETAVIA KENAN
Title or Position: OWNER
Credential:
Phone: 336-303-0587