Provider Demographics
NPI:1174694061
Name:DR. JACK DOLBIN D.C, P.C
Entity type:Organization
Organization Name:DR. JACK DOLBIN D.C, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:TICE
Authorized Official - Last Name:DOLBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-621-4390
Mailing Address - Street 1:700 SCHUYLKILL MANOR RD
Mailing Address - Street 2:SUITE #4
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3849
Mailing Address - Country:US
Mailing Address - Phone:570-621-4390
Mailing Address - Fax:570-621-4296
Practice Address - Street 1:700 SCHUYLKILL MANOR RD
Practice Address - Street 2:SUITE #4
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3849
Practice Address - Country:US
Practice Address - Phone:570-621-4390
Practice Address - Fax:570-621-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006103L111N00000X
PADC002615L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA111353Medicare PIN