Provider Demographics
NPI:1073675252
Name:JAC OPTICAL
Entity Type:Organization
Organization Name:JAC OPTICAL
Other - Org Name:I'LL BE SEEING YOU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMERLENGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-356-3249
Mailing Address - Street 1:262 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1219
Mailing Address - Country:US
Mailing Address - Phone:718-356-3249
Mailing Address - Fax:
Practice Address - Street 1:262 ARDEN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1219
Practice Address - Country:US
Practice Address - Phone:718-356-3249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623063Medicaid
NY02623063Medicaid