MEDICARE: PATJAC, 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	332H00000X	Eyewear Supplier		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C02754	OTHER		WISCONSIN PHY
2	65209PE	OTHER	MN	BCBS
3	65208PE	OTHER	MN	BCBS
4	102081	OTHER	MN	COLE
5	65377	OTHER	MN	HP
6	110495	OTHER	MN	UCARE
7	21-20963	OTHER	MN	MEDICA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033118302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATJAC, INC.

Provider Business Mailing Address
First Line	:	4118 W DIVISION ST
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-3706
Country	:	US
Telephone Number	:	320-252-2021
Fax Number	:	320-252-7416

Provider Business Practice Location Address
First Line	:	4118 W DIVISION ST
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-3706
Country	:	US
Telephone Number	:	320-252-2021
Fax Number	:	320-252-7416

Authorized Official
Title or Position	:	FRANCHISE OWNER
Name	:	MR. PATRICK O KANE
Credential	:	OPTICIAN
Telephone Number	:	320-252-2021

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	07/21/2022

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Directions to “PATJAC, INC. ” Practice Location

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