Provider Demographics
NPI:1477730919
Name:CHAD J. JACKSON, OD, PLLC
Entity Type:Organization
Organization Name:CHAD J. JACKSON, OD, PLLC
Other - Org Name:BELLA VISTA FAMILY EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-874-2020
Mailing Address - Street 1:6575 BELDING RD NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7418
Mailing Address - Country:US
Mailing Address - Phone:616-874-2020
Mailing Address - Fax:616-874-2773
Practice Address - Street 1:6575 BELDING RD NE
Practice Address - Street 2:SUITE D
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7418
Practice Address - Country:US
Practice Address - Phone:616-874-2020
Practice Address - Fax:616-874-2773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4925900Medicaid
MIY44126Medicare UPIN
MI4925900Medicaid
MI5580950001Medicare NSC