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General NPI Number Information
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NPI Number | 1073882783
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Entity Type | Organization
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Legal Business Name | JACKIES RETIREMENT LLC
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Dates
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Enumeration Date | 12/26/2011
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Last Update Date | 12/26/2011
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Provider Practice Location Address
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Address Line | 1675 CANON AVE NW
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City | PALM BAY
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State | FL
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Zip | 32907-8528
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Country | US
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Telephone | 321-420-3916
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Fax |
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Provider Business Mailing Address
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Address Line | 1675 CANON AVE NW
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City | PALM BAY
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State | FL
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Zip | 32907-8528
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Country | US
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Telephone | 321-420-3916
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | MS. JACQUELINE B WRIGHT
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Credential |
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Telephone | 321-420-3916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | AL12053
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License Number State | FL
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