Provider Demographics
NPI:1144793720
Name:JACK DOBY GARDEN CITY, LLC
Entity type:Organization
Organization Name:JACK DOBY GARDEN CITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAGELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-394-0001
Mailing Address - Street 1:JACK DOBY GARDEN CITY, LLC
Mailing Address - Street 2:928 OLD COUNTRY ROAD
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-394-0001
Mailing Address - Fax:516-394-0003
Practice Address - Street 1:JACK DOBY GARDEN CITY, LLC
Practice Address - Street 2:928 OLD COUNTRY ROAD
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-394-0001
Practice Address - Fax:516-394-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier