Provider Demographics
NPI:1326602392
Name:RX OPTICAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:RX OPTICAL LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JEPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-342-0003
Mailing Address - Street 1:1825 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2762
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:
Practice Address - Street 1:930 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1586
Practice Address - Country:US
Practice Address - Phone:269-342-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C976550OtherBCBS