Provider Demographics
NPI:1700136041
Name:W-J OPTICAL
Entity Type:Organization
Organization Name:W-J OPTICAL
Other - Org Name:OPTICAL EXPRESSIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-660-3687
Mailing Address - Street 1:2101 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-1607
Mailing Address - Country:US
Mailing Address - Phone:605-665-6181
Mailing Address - Fax:605-665-6181
Practice Address - Street 1:2101 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-1607
Practice Address - Country:US
Practice Address - Phone:605-665-6181
Practice Address - Fax:605-665-6181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9281330Medicaid