Provider Demographics
NPI:1164649505
Name:OPTICAL SHOPPE OF JAX INC
Entity Type:Organization
Organization Name:OPTICAL SHOPPE OF JAX INC
Other - Org Name:OPTICAL SHOPPE OF JAX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-730-3388
Mailing Address - Street 1:3636 UNIVERSITY BLVD S A1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4210
Mailing Address - Country:US
Mailing Address - Phone:904-730-3388
Mailing Address - Fax:904-730-3388
Practice Address - Street 1:3636 UNIVERSITY BLVD S A-1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4210
Practice Address - Country:US
Practice Address - Phone:904-730-3388
Practice Address - Fax:904-730-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4035360001Medicare NSC