Provider Demographics
NPI:1568577641
Name:KOKOMO OPTICAL INC
Entity Type:Organization
Organization Name:KOKOMO OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:764-555-1810
Mailing Address - Street 1:1400 E HILLSBORO BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-4202
Mailing Address - Country:US
Mailing Address - Phone:765-455-1810
Mailing Address - Fax:206-339-3251
Practice Address - Street 1:501 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3742
Practice Address - Country:US
Practice Address - Phone:800-426-5598
Practice Address - Fax:206-339-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0002243580332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0816250001Medicare ID - Type Unspecified