1093704850 NPI number — DELTAVISION OPTICAL CENTER PC

Table of content: (NPI 1093704850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093704850 NPI number — DELTAVISION OPTICAL CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTAVISION OPTICAL CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093704850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
G3541 MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-1235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-732-8610
Provider Business Mailing Address Fax Number:
810-732-6813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
G3541 MILLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-1235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-732-8610
Provider Business Practice Location Address Fax Number:
810-732-6813
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FOON
Authorized Official First Name:
IRVING
Authorized Official Middle Name:
IRA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-732-8610

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 230370 . This is a "NVA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1004305 . This is a "MCLAREN MEDICAID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 31986 . This is a "COLE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7333067 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 27671 . This is a "SPECTERA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com