Provider Demographics
NPI:1922347848
Name:JAYDEN2006
Entity Type:Organization
Organization Name:JAYDEN2006
Other - Org Name:PEARLE VISION COON RAPIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-599-0153
Mailing Address - Street 1:12256 LAKEVIEW DRIVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:612-599-0153
Mailing Address - Fax:
Practice Address - Street 1:13195 WEAVER LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9410
Practice Address - Country:US
Practice Address - Phone:612-599-0153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty