Provider Demographics
NPI:1396056792
Name:JOB OPTICAL, INC.
Entity type:Organization
Organization Name:JOB OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/ OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:ABO CERTIFIED
Authorized Official - Phone:269-687-2800
Mailing Address - Street 1:211 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2220
Mailing Address - Country:US
Mailing Address - Phone:269-687-2800
Mailing Address - Fax:269-687-2800
Practice Address - Street 1:211 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2220
Practice Address - Country:US
Practice Address - Phone:269-687-2800
Practice Address - Fax:269-687-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332H00000X
MI332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier