Provider Demographics
NPI:1790106136
Name:RX OPTICAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:RX OPTICAL LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:YONKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-342-0003
Mailing Address - Street 1:1700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2779
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:269-342-4284
Practice Address - Street 1:1844 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4869
Practice Address - Country:US
Practice Address - Phone:616-957-2993
Practice Address - Fax:616-957-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C97655Medicare PIN