1700136041 NPI number — W-J OPTICAL

Table of content: (NPI 1700136041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700136041 NPI number — W-J OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W-J OPTICAL
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:
OPTICAL EXPRESSIONS
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:
1700136041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 BROADWAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YANKTON
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57078-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-665-6181
Provider Business Mailing Address Fax Number:
605-665-6181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YANKTON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57078-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-665-6181
Provider Business Practice Location Address Fax Number:
605-665-6181
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KINGSLEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
605-660-3687

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9281330 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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