=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336743632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JA VISION ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2020
-----------------------------------------------------
Last Update Date | 11/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 CORPORATE DR STE 2
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18045-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-258-2442
-----------------------------------------------------
Fax | 610-258-7961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 CORPORATE DR STE 2
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18045-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-258-2442
-----------------------------------------------------
Fax | 610-258-7961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER/ OPTOMETRIST ASSIST
-----------------------------------------------------
Name | RACHEL MOBLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-258-2442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------