Provider Demographics
NPI:1528013380
Name:JAK ENTERPRISE INC
Entity Type:Organization
Organization Name:JAK ENTERPRISE INC
Other - Org Name:BARD OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PREIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-9540
Mailing Address - Street 1:7720 N CRESTLINE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1907
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:
Practice Address - Street 1:206 W 1ST ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1344
Practice Address - Country:US
Practice Address - Phone:309-944-5351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0295700019OtherDMERC MEDICARE LOCATION #
IL=========OtherFEIN #
IL0295700019OtherDMERC MEDICARE LOCATION #