Provider Demographics
NPI:1649448374
Name:JCC LLC
Entity type:Organization
Organization Name:JCC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-592-7300
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:14307 JARRETTSVILLE PIKE
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-0038
Mailing Address - Country:US
Mailing Address - Phone:410-592-7300
Mailing Address - Fax:410-666-0348
Practice Address - Street 1:14307 JARRETTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1763
Practice Address - Country:US
Practice Address - Phone:410-592-7300
Practice Address - Fax:410-666-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01332111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD382MMedicare PIN