Provider Demographics
NPI:1518035187
Name:PILLEN, JUBAL S (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JUBAL
Middle Name:S
Last Name:PILLEN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 JUNCTION AVE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1632
Mailing Address - Country:US
Mailing Address - Phone:605-347-9117
Mailing Address - Fax:605-347-8652
Practice Address - Street 1:1020 JUNCTION AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1632
Practice Address - Country:US
Practice Address - Phone:605-347-9117
Practice Address - Fax:605-347-8652
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDNA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203230Medicaid