Provider Demographics
NPI:1114100740
Name:JACKSON EYE CARE, INC
Entity Type:Organization
Organization Name:JACKSON EYE CARE, INC
Other - Org Name:BARRY JACKSON OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-586-1500
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-1574
Mailing Address - Country:US
Mailing Address - Phone:435-586-1500
Mailing Address - Fax:435-865-0784
Practice Address - Street 1:51 E 400 N
Practice Address - Street 2:SUITE 4A
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2686
Practice Address - Country:US
Practice Address - Phone:435-586-1500
Practice Address - Fax:435-865-0784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375344-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528882505001Medicaid
UTU78782Medicare UPIN
UT0000057350Medicare PIN
UT528882505001Medicaid