Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1063632412 |
---|---|
Provider Name | Robert H Jansen JR. |
First Address | Broadview, IL 60155-3850 |
Second Address | Broadview, IL 60155-3850 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0001618790 | BLUE CROSS BLUE SHIELD (01) | IL |
165381 | EYEMED (01) | IL |