Provider Demographics
NPI:1083158372
Name:JAK ENTERPRISES DBA JAK OPTICAL LABORATORIES
Entity Type:Organization
Organization Name:JAK ENTERPRISES DBA JAK OPTICAL LABORATORIES
Other - Org Name:JAK OPTICAL LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-9540
Mailing Address - Street 1:PO BOX 3333
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-3333
Mailing Address - Country:US
Mailing Address - Phone:309-713-1762
Mailing Address - Fax:309-966-0922
Practice Address - Street 1:8309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2170
Practice Address - Country:US
Practice Address - Phone:800-654-2833
Practice Address - Fax:800-322-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier