MEDICARE: JCC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	S01332	MD

General Provider Information

NPI Number	:	1649448374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JCC LLC

Provider Business Mailing Address
First Line	:	PO BOX 38
Second Line	:	14307 JARRETTSVILLE PIKE
City	:	PHOENIX
State	:	MD
Zip	:	21131-0038
Country	:	US
Telephone Number	:	410-592-7300
Fax Number	:	410-666-0348

Provider Business Practice Location Address
First Line	:	14307 JARRETTSVILLE PIKE
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1763
Country	:	US
Telephone Number	:	410-592-7300
Fax Number	:	410-666-0348

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. DANIEL THOMAS WISE
Credential	:	D.C.
Telephone Number	:	410-592-7300

Provider Enumeration Date	:	02/15/2008
Last Update Date	:	02/15/2008

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Directions to “JCC LLC ” Practice Location

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