Provider Demographics
NPI:1972626141
Name:JACK HAWKS PC
Entity type:Organization
Organization Name:JACK HAWKS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-849-3811
Mailing Address - Street 1:9191 W THUNDERBIRD ROAD
Mailing Address - Street 2:D 105
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-849-3811
Mailing Address - Fax:623-849-5221
Practice Address - Street 1:9191 W THUNDERBIRD ROAD
Practice Address - Street 2:D 105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-849-3811
Practice Address - Fax:623-849-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty