Basic Information
Provider Information | |||||||||
NPI: | 1245627173 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JFJ EYECARE LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | QUANTUM VISION CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3990 N ILLINOIS ST | ||||||||
Address2: |   | ||||||||
City: | SWANSEA | ||||||||
State: | IL | ||||||||
PostalCode: | 622261919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182771130 | ||||||||
FaxNumber: | 6182774917 | ||||||||
Practice Location | |||||||||
Address1: | 220 RICHMOND AVE E | ||||||||
Address2: |   | ||||||||
City: | MATTOON | ||||||||
State: | IL | ||||||||
PostalCode: | 619384652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362004393 | ||||||||
FaxNumber: | 2172343930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2015 | ||||||||
LastUpdateDate: | 06/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | BART | ||||||||
AuthorizedOfficialMiddleName: | AARON | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6185321082 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 036104178 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 036104178 | 01 | IL | LICENSE | OTHER |