Provider Demographics
NPI:1659635209
Name:AMJ OPTOMETRIC SERVICES PSC
Entity Type:Organization
Organization Name:AMJ OPTOMETRIC SERVICES PSC
Other - Org Name:EYE Q VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-387-6695
Mailing Address - Street 1:111 STAR ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4889
Mailing Address - Country:US
Mailing Address - Phone:507-387-6695
Mailing Address - Fax:507-668-0358
Practice Address - Street 1:111 STAR ST STE 101
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4889
Practice Address - Country:US
Practice Address - Phone:507-387-6695
Practice Address - Fax:507-668-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3175152W00000X
MN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003764Medicare UPIN
MN7533400001Medicare NSC