Provider Demographics
NPI:1639391832
Name:NIEVES, JOSE L (OPTICAL)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:L
Last Name:NIEVES
Suffix:
Gender:M
Credentials:OPTICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 E STATE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2044
Mailing Address - Country:US
Mailing Address - Phone:815-397-5940
Mailing Address - Fax:815-397-5947
Practice Address - Street 1:4010 E STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2044
Practice Address - Country:US
Practice Address - Phone:815-397-5940
Practice Address - Fax:815-397-5947
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician