Provider Demographics
NPI:1508035767
Name:REX JOHNSON
Entity Type:Organization
Organization Name:REX JOHNSON
Other - Org Name:EAGLE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTICAN
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-889-5511
Mailing Address - Street 1:269 SW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1972
Mailing Address - Country:US
Mailing Address - Phone:541-889-5511
Mailing Address - Fax:541-889-9911
Practice Address - Street 1:269 SW 19TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1972
Practice Address - Country:US
Practice Address - Phone:541-889-5511
Practice Address - Fax:541-889-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0428110001Medicare NSC