Provider Demographics
NPI:1033118302
Name:PATJAC, INC.
Entity Type:Organization
Organization Name:PATJAC, INC.
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:O
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:320-252-2021
Mailing Address - Street 1:4118 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3706
Mailing Address - Country:US
Mailing Address - Phone:320-252-2021
Mailing Address - Fax:320-252-7416
Practice Address - Street 1:4118 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3706
Practice Address - Country:US
Practice Address - Phone:320-252-2021
Practice Address - Fax:320-252-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02754OtherWISCONSIN PHY
MN65209PEOtherBCBS
MN65208PEOtherBCBS
MN102081OtherCOLE
MN65377OtherHP
MN110495OtherUCARE
MN21-20963OtherMEDICA
MN383663100Medicaid
MN383663100Medicaid