MEDICARE: JAJ EYEWEAR 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	156FC0801X	Contact Lens Fitter
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1275827107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAJ EYEWEAR INC.

Provider Business Mailing Address
First Line	:	740 MAIN ST
Second Line	:	SUITE 100
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55118-3762
Country	:	US
Telephone Number	:	651-686-9393
Fax Number	:	651-556-2568

Provider Business Practice Location Address
First Line	:	740 MAIN ST
Second Line	:	SUITE 100
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55118-3762
Country	:	US
Telephone Number	:	651-686-9393
Fax Number	:	651-556-2568

Authorized Official
Title or Position	:	OWNER
Name	:	MELAINA J GROVER
Credential	:
Telephone Number	:	651-686-9393

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	06/08/2011

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