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General NPI Number Information
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NPI Number | 1083161830
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Entity Type | Organization
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Legal Business Name | JACKLAB, INC
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Dates
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Enumeration Date | 09/08/2016
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Last Update Date | 09/08/2016
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Provider Practice Location Address
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Address Line | 6369 MILL ST SUITE 201
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City | RHINEBECK
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State | NY
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Zip | 12572-1406
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Country | US
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Telephone | 845-516-4836
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Fax | 845-516-4233
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Provider Business Mailing Address
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Address Line | 6369 MILL ST SUITE 201
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City | RHINEBECK
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State | NY
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Zip | 12572-1406
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Country | US
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Telephone | 845-516-4836
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Fax | 845-516-4233
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN F MCNULTY
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Credential | M.D.
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Telephone | 845-516-4836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 206911
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License Number State | NY
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