1598881336 NPI number — JACKSON VISION CENTER, LLC

Table of content: (NPI 1598881336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598881336 NPI number — JACKSON VISION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON VISION CENTER, 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:
Provider Other Organization Name Type Code:
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:
1598881336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W194N16747 EAGLE DR
Provider Second Line Business Mailing Address:
SUITE N
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53037-9797
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-677-4313
Provider Business Mailing Address Fax Number:
262-677-4396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W194N16747 EAGLE DR
Provider Second Line Business Practice Location Address:
SUITE N
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53037-9797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-677-4313
Provider Business Practice Location Address Fax Number:
262-677-4396
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BARARI
Authorized Official First Name:
ZHALEH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
262-677-4313

Provider Taxonomy Codes

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

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

  • Identifier: 38615500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com