Provider Demographics
NPI:1275552382
Name:PATJAC INC.
Entity Type:Organization
Organization Name:PATJAC INC.
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-252-0509
Mailing Address - Street 1:1301 33RD ST S STE 104
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9668
Mailing Address - Country:US
Mailing Address - Phone:320-252-0509
Mailing Address - Fax:320-252-5386
Practice Address - Street 1:1301 33RD ST S
Practice Address - Street 2:STE 104
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9668
Practice Address - Country:US
Practice Address - Phone:320-252-0509
Practice Address - Fax:320-252-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN832255400Medicaid
MN563G3PEOtherBCBS
MN21-00759OtherMEDICA
MN65377OtherHEALTHPARTNERS
MN562G3PEOtherBCBS
MNJ738OtherUCARE
MN832255400Medicaid
MN563G3PEOtherBCBS