Basic Information
| Provider Information | |||||||||
| NPI: | 1609815992 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAK ENTERPRISES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BARD OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 HICKORY POINT DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FORSYTH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625351085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178753724 | ||||||||
| FaxNumber: | 2178753840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096939540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 332B00000X | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.