1629136734 NPI number — J & R OPTICAL

Table of content: (NPI 1629136734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629136734 NPI number — J & R OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J & R 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:
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:
1629136734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1461 CANTON MART RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39211-5413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-977-0272
Provider Business Mailing Address Fax Number:
601-977-0689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1461 CANTON MART RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-5413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-977-0272
Provider Business Practice Location Address Fax Number:
601-977-0689
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
601-977-0272

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com