Provider Demographics
NPI:1912181967
Name:JACKSON EYE CARE, INC
Entity Type:Organization
Organization Name:JACKSON EYE CARE, INC
Other - Org Name:RUSSELL B JACKSON OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-743-6572
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:UT
Mailing Address - Zip Code:84631-0073
Mailing Address - Country:US
Mailing Address - Phone:435-743-6572
Mailing Address - Fax:435-743-5558
Practice Address - Street 1:210 S 100 W
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631
Practice Address - Country:US
Practice Address - Phone:435-743-6572
Practice Address - Fax:435-743-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375344-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528882505001Medicaid
UT000057350Medicare PIN
UT528882505001Medicaid
UT5241060001Medicare NSC