Provider Demographics
NPI:1457541179
Name:RX OPTICAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:RX OPTICAL LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-342-0003
Mailing Address - Street 1:1825 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2759
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:269-342-4284
Practice Address - Street 1:1720 E STERNBERG RD
Practice Address - Street 2:SUITE 20
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-7762
Practice Address - Country:US
Practice Address - Phone:231-798-7230
Practice Address - Fax:269-342-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0733500043Medicare NSC