Provider Demographics
NPI:1417131046
Name:N & J OPTICAL SUPPLY INC
Entity Type:Organization
Organization Name:N & J OPTICAL SUPPLY INC
Other - Org Name:PROFESSIONAL VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-755-2150
Mailing Address - Street 1:2110 12TH ST
Mailing Address - Street 2:PO BOX 270
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-2056
Mailing Address - Country:US
Mailing Address - Phone:712-755-2150
Mailing Address - Fax:712-755-7555
Practice Address - Street 1:2110 12TH ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-2056
Practice Address - Country:US
Practice Address - Phone:712-755-2150
Practice Address - Fax:712-755-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1284455Medicaid
IAT83772Medicare UPIN
IA5337340001Medicare NSC
IAI14764Medicare PIN