Provider Demographics
NPI:1487990198
Name:CLINE, JACK BYRON (LVN)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:BYRON
Last Name:CLINE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 C ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5121
Mailing Address - Country:US
Mailing Address - Phone:619-615-0439
Mailing Address - Fax:619-615-3197
Practice Address - Street 1:427 C ST STE 212
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5121
Practice Address - Country:US
Practice Address - Phone:619-238-4180
Practice Address - Fax:619-238-4245
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92322164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse