Provider Demographics
NPI:1609292077
Name:JD EYES, INC
Entity Type:Organization
Organization Name:JD EYES, INC
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARA
Authorized Official - Middle Name:DURICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-355-8512
Mailing Address - Street 1:12771 RIVERDALE BLVD NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1262
Mailing Address - Country:US
Mailing Address - Phone:763-421-1220
Mailing Address - Fax:
Practice Address - Street 1:12771 RIVERDALE BLVD NW
Practice Address - Street 2:SUITE 103
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1262
Practice Address - Country:US
Practice Address - Phone:763-421-1220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN005323600Medicaid
MN005323600Medicaid