Basic Information
Provider Information | |||||||||
NPI: | 1295778587 | ||||||||
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: | 111 W LINCOLN ST | ||||||||
Address2: |   | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622202019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182771130 | ||||||||
FaxNumber: | 6182776651 | ||||||||
Practice Location | |||||||||
Address1: | 3990 N ILLINOIS | ||||||||
Address2: |   | ||||||||
City: | SWANSEA | ||||||||
State: | IL | ||||||||
PostalCode: | 62226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362004393 | ||||||||
FaxNumber: | 6182776651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 06/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | BART | ||||||||
AuthorizedOfficialMiddleName: | AARON | ||||||||
AuthorizedOfficialTitleorPosition: | OPHTHALMOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 6182771130 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.