Basic Information
| Provider Information | |||||||||
| NPI: | 1497273403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RX OPTICAL LABORATORIES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 SOUTH PARK ST | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490012779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693420003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3445 HENRY ST | ||||||||
| Address2: | |||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312200223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2017 | ||||||||
| LastUpdateDate: | 12/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | JEPSON | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2693420003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 900C976550 | 01 | MI | BCBS OF MICHIGAN | OTHER |