1114114428 NPI number — MAC OPTICAL

Table of content: (NPI 1114114428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114114428 NPI number — MAC OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAC OPTICAL
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:
DIAMOND OPTICAL CARE
Provider Other Organization Name Type Code:
3
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:
1114114428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 N LEROY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48430-2763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-629-2041
Provider Business Mailing Address Fax Number:
810-629-9366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 N LEROY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-2763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-629-2041
Provider Business Practice Location Address Fax Number:
810-629-9366
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
248-887-4861

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003723 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0B51128 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900B51128 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0N11050 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3442884 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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