1679660849 NPI number — BLACK AND WHITE LOOK OPTICAL CORPORATION

Table of content: (NPI 1679660849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679660849 NPI number — BLACK AND WHITE LOOK OPTICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK AND WHITE LOOK OPTICAL CORPORATION
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:
1679660849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15675 W TEN MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-2188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-557-6444
Provider Business Mailing Address Fax Number:
248-557-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15675 W TEN MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-2188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-557-6444
Provider Business Practice Location Address Fax Number:
248-557-6501
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRYE
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
248-557-6444

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 3282118 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900F378590 . This is a "BLUE CROSS PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 230892 . This is a "NVA PIN#" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 024599 . This is a "MIDWEST HEALTH PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 113750 . This is a "TOTAL HEALTH PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6719 . This is a "CO/OP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F37859 . This is a "BLUE CROSS FEDERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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