Provider Demographics
NPI:1124179346
Name:JARTLL CORP
Entity Type:Organization
Organization Name:JARTLL CORP
Other - Org Name:OPTICAL WORLD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:KINGERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:238-871-1234
Mailing Address - Street 1:15336 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2215
Mailing Address - Country:US
Mailing Address - Phone:313-836-1666
Mailing Address - Fax:313-836-1066
Practice Address - Street 1:15336 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2215
Practice Address - Country:US
Practice Address - Phone:313-836-1666
Practice Address - Fax:313-836-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124179346Medicaid