Provider Demographics
NPI:1235272337
Name:JAN'S OPTICAL SHOP OF CRYSTAL RIVER
Entity Type:Organization
Organization Name:JAN'S OPTICAL SHOP OF CRYSTAL RIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGERING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-795-7228
Mailing Address - Street 1:597 SE US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4807
Mailing Address - Country:US
Mailing Address - Phone:352-795-7228
Mailing Address - Fax:
Practice Address - Street 1:597 SE US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4807
Practice Address - Country:US
Practice Address - Phone:352-795-7228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5550680001Medicare ID - Type UnspecifiedPROVIDER NO