Provider Demographics
NPI:1831323419
Name:JAK ENTERPRISES, INC.
Entity Type:Organization
Organization Name:JAK ENTERPRISES, INC.
Other - Org Name:BARD OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-9540
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:390-693-9542
Practice Address - Street 1:3323 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1101
Practice Address - Country:US
Practice Address - Phone:815-220-0652
Practice Address - Fax:815-220-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208479Medicare PIN
0295700023Medicare NSC