Healthcare Provider Details

I. General information

NPI: 1558330076
Provider Name (Legal Business Name): JACK FACCIOLO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SECLUDED LN
RIO GRANDE NJ
08242-1546
US

IV. Provider business mailing address

1 SECLUDED LN
RIO GRANDE NJ
08242-1546
US

V. Phone/Fax

Practice location:
  • Phone: 609-368-1952
  • Fax:
Mailing address:
  • Phone: 609-368-1952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMB039210
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: