Provider Demographics
NPI:1346459500
Name:B J RUST JR
Entity Type:Organization
Organization Name:B J RUST JR
Other - Org Name:OPTICAL SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:B.
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUST
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:817-338-1121
Mailing Address - Street 1:4825 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-4150
Mailing Address - Country:US
Mailing Address - Phone:817-731-4646
Mailing Address - Fax:817-731-4646
Practice Address - Street 1:4825 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4150
Practice Address - Country:US
Practice Address - Phone:817-731-4646
Practice Address - Fax:817-731-4646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDR0128332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1070120001Medicare NSC