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General NPI Number Information
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NPI Number | 1528013380
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Entity Type | Organization
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Legal Business Name | JAK ENTERPRISE INC
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 206 W 1ST ST
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City | GENESEO
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State | IL
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Zip | 61254-1344
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Country | US
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Telephone | 309-944-5351
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Fax |
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Provider Business Mailing Address
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Address Line | 7720 N CRESTLINE DR
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City | PEORIA
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State | IL
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Zip | 61615-1907
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Country | US
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Telephone | 309-693-9540
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Fax |
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Authorized Official
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Title or Position | PREIDENT
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Name | DIANA J HALL
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Credential |
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Telephone | 309-693-9540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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