MEDICARE: JARTLL CORP

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124179346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JARTLL CORP

Provider Business Mailing Address
First Line	:	15336 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-2215
Country	:	US
Telephone Number	:	313-836-1666
Fax Number	:	313-836-1066

Provider Business Practice Location Address
First Line	:	15336 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-2215
Country	:	US
Telephone Number	:	313-836-1666
Fax Number	:	313-836-1066

Authorized Official
Title or Position	:	INSURANCE SUPERVISOR
Name	:	HEATHER M KINGERY
Credential	:
Telephone Number	:	238-871-1234

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	02/07/2012

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Directions to “JARTLL CORP ” Practice Location

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