1619271996 NPI number — FERRIS OPTICAL CORP

Table of content: ANN TERESA RUPP FNP (NPI 1790243632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619271996 NPI number — FERRIS OPTICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FERRIS OPTICAL CORP
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:
Provider Other Organization Name Type Code:
6
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:
1619271996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 E GANSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-789-6171
Provider Business Mailing Address Fax Number:
517-789-6200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 E GANSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49201-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-789-6171
Provider Business Practice Location Address Fax Number:
517-789-6200
Provider Enumeration Date:
12/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FERRIS
Authorized Official First Name:
JAN
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
OWNER - PRESIDENT - OPTOMETRIST
Authorized Official Telephone Number:
517-789-6171

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  152W00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 945036409 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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