MEDICARE: RX OPTICAL LABORATORIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901003762	MI

General Provider Information

NPI Number	:	1679819593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RX OPTICAL LABORATORIES, INC.

Provider Business Mailing Address
First Line	:	1825 S PARK ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49001-2779
Country	:	US
Telephone Number	:	269-342-0003
Fax Number	:	269-342-4284

Provider Business Practice Location Address
First Line	:	4022 PLAINFIELD AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1608
Country	:	US
Telephone Number	:	616-363-1868
Fax Number	:	616-363-2246

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEPHAN JEPSON
Credential	:
Telephone Number	:	269-342-0003

Provider Enumeration Date	:	12/20/2012
Last Update Date	:	12/11/2017

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