JACK CITY, LLC (NPI# 1376002931) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1376002931 |
| Entity Type | Organization |
| Organization Name | JACK CITY, LLC |
| Practice Address |
290 Pleasant St Apt 212 Watertown MA 02472-2429 |
| Practice Telephone | 6173931709 |
| Practice Fax Number | 6177546420 |
| Mailing Telephone | 6173931709 |
| Mailing Fax Number | 6177546420 |
| Enumeration Date | 2019-03-13 |
| Last Update Date | 2020-01-23 |
| Authorized Official Name | CODEY D GILLUM (CEO) |
| Authorized Official Telephone | 6173931709 |
| Authorized Official Credential | PA-C |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 363AS0400X |
Physician Assistant Specialization: Surgical Technologist |
Physician Assistants & Advanced Practice Nursing Providers | ||
| Y | 332B00000X | Durable Medical Equipment & Medical Supplies | Suppliers |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 2014 Washington St, Newton, MA 024621607 | 6172436000 | |
| 125 Parker Hill Ave # 550, Boston, MA 021202847 | 6176025707 | 8775474951 |
| 125 Parker Hill Ave # 4, Boston, MA 021202847 | 6177546569 | 6171546420 |
| 125 Parker Hill Ave, Boston, MA 021202847 | 6177545000 | |
| 159 Wells Ave, Newton, MA 024593301 | 6172435777 | |
| 40 Allied Dr, Dedham, MA 020266146 | 6177545000 |
| Street Address |
290 PLEASANT ST APT 212 |
| City | WATERTOWN |
| State | MA |
| Zip Code | 02472-2429 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1548735327 | Gladys Nakungu Kasansula | Counselor | Square Medical Group, 124 Watertown Street, Suite 2d, Watertown, MA 02472 | 2018-10-09 |
| 1447741962 | Hannah Edward | Optometrist | 550 Arsenal Street, Watertown, MA 02472 | 2018-05-21 |
| 1982193504 | Ruth Audrey Silverstein | Social Worker | Perkins School for The Blind, 175 North Beacon Street, Watertown, MA 02472 | 2018-05-09 |
| 1376067355 | Mostafa Medhati | Acupuncturist | 265 Lexington St., Watertown, MA 02472 | 2017-08-01 |
| 1003346313 | Eric Trant | Specialist/Technologist | 50 Columbia Street, Watertown, MA 02472 | 2017-06-19 |
| 1477007730 | Neangkanika Chea | Nurse Practitioner | 2 Repton Place, Apt 2204, Watertown, MA 02472 | 2016-08-04 |
| 1396128120 | Michelle Soares Darocha | Dentist | 18 Hovey Street, Watertown, MA 02472 | 2015-06-29 |
| 1760875496 | Ece Evin Yildirim | Acupuncturist | 557 Mt. Auburn St, Watertown, MA 02472 | 2015-03-05 |
| 1396140927 | Fabrizia Torazzi | Behavioral Analyst | 51 Water Street, Suite 200, Watertown, MA 02472 | 2014-10-24 |
| 1265774392 | Emilia Ann Fulop | Social Worker | 127 North Beacon Street, Watertown, MA 02472 | 2013-03-27 |
| Find all providers in zip 02472 | ||||
| Taxonomy Code | 332B00000X |
| Grouping | Suppliers |
| Classification | Durable Medical Equipment & Medical Supplies |
| A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient’s use in the home and that are usable for an extended period of time. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1801414156 | Genoa Healthcare, LLC | Durable Medical Equipment & Medical Supplies | 122 Court Street, Empsall Bldg, Room 212, Watertown, NY 13601 | 2020-07-13 |
| 1740649029 | Cvs Pharmacy Inc | Durable Medical Equipment & Medical Supplies | 655 Mount Auburn St, Watertown, MA 02472-2017 | 2016-02-16 |
| 1841340163 | Cvs Albany LLC | Durable Medical Equipment & Medical Supplies | 21800 Towne Center Dr, Watertown, NY 13601-5898 | 2007-01-11 |
| 1871642579 | Walgreen Co. | Durable Medical Equipment & Medical Supplies | 1655 State St, Watertown, NY 13601-3555 | 2007-01-10 |
| 1952465387 | Associated Healthcare Systems, Inc | Durable Medical Equipment & Medical Supplies | 22566 Fisher Rd, Watertown, NY 13601-1050 | 2006-12-20 |
| 1144396102 | Avera Home Medical Equipment, LLC | Durable Medical Equipment & Medical Supplies | 1508 4th St Ne, Watertown, SD 57201-6824 | 2006-11-28 |
| 1609941483 | Hanger Prosthetics & Orthotics East Inc | Durable Medical Equipment & Medical Supplies | 19472 Nys Route 11, Watertown, NY 13601 | 2006-11-21 |
| 1831298181 | Eckerd Corporation | Durable Medical Equipment & Medical Supplies | 1222 Arsenal Street, Watertown, NY 13601-2230 | 2006-09-22 |
| 1922117308 | Rite Aid of Connecticut Inc | Durable Medical Equipment & Medical Supplies | 1271 Main Street, Watertown, CT 06795-3107 | 2006-08-30 |
| 1083723472 | Rite Aid of New York Inc | Durable Medical Equipment & Medical Supplies | 842 State Street, Watertown, NY 13601-2843 | 2006-08-30 |
| Find all providers in WATERTOWN | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.