Provider Demographics
NPI:1851500524
Name:JRGOLD, INC
Entity Type:Organization
Organization Name:JRGOLD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GOLDSTEIM
Authorized Official - Suffix:I
Authorized Official - Credentials:OD
Authorized Official - Phone:217-258-8466
Mailing Address - Street 1:1120 LAKE LAND BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5562
Mailing Address - Country:US
Mailing Address - Phone:217-258-8466
Mailing Address - Fax:217-258-8443
Practice Address - Street 1:1120 LAKE LAND BLVD STE 1
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5562
Practice Address - Country:US
Practice Address - Phone:217-258-8466
Practice Address - Fax:217-258-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007322152W00000X
IL332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007322Medicaid
677320Medicare PIN
IL046007322Medicaid