Provider Demographics
NPI:1356470330
Name:J & K OPTICAL, INC.
Entity Type:Organization
Organization Name:J & K OPTICAL, INC.
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAULER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-896-0610
Mailing Address - Street 1:74 COULTER AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2308
Mailing Address - Country:US
Mailing Address - Phone:610-896-0610
Mailing Address - Fax:
Practice Address - Street 1:74 COULTER AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2308
Practice Address - Country:US
Practice Address - Phone:610-896-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000001626332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA205866OtherPA BLUE CHIELD
PA0143830001Medicare NSC