1598075160 NPI number — DIRECT OPTICAL OF CANTON, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598075160 NPI number — DIRECT OPTICAL OF CANTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIRECT OPTICAL OF CANTON, LLC
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:
1598075160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41840 FORD ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-981-1760
Provider Business Mailing Address Fax Number:
734-981-1574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41840 FORD ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-981-1760
Provider Business Practice Location Address Fax Number:
734-981-1574
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MIHAJLOVSKI
Authorized Official First Name:
MARIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-981-1760

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NONE . This is a "DELTA VISION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "MECA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CP2724 . This is a "EYEMED VISION CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "MEBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 230266 . This is a "NATIONAL VISION ADMINISTRATORS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 900F376990 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "SUPERIOR VISION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 58695 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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