Healthcare Provider Details

I. General information

NPI: 1558644930
Provider Name (Legal Business Name): JFJ EYECARE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PROFESSIONAL PARK DR
MARYVILLE IL
62062-5672
US

IV. Provider business mailing address

111 W LINCOLN ST
BELLEVILLE IL
62220-2019
US

V. Phone/Fax

Practice location:
  • Phone: 636-200-4393
  • Fax: 618-288-4583
Mailing address:
  • Phone: 618-277-1130
  • Fax: 618-277-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SANDRA LYNN CUMMINS
Title or Position: INSURANCE DEPT. ADMINISTRATOR
Credential:
Phone: 618-277-1130