1316010218 NPI number — JJS OPTICAL LLC

Table of content: (NPI 1316010218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316010218 NPI number — JJS OPTICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JJS OPTICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
METRO OPTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316010218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 5TH ST E STE 281
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55101-1862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-227-6506
Provider Business Mailing Address Fax Number:
651-288-4740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 5TH ST E STE 281
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-1862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-227-6506
Provider Business Practice Location Address Fax Number:
651-227-6507
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
651-227-6506

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  MN1582 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 165105600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021823500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 869675600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".