1043350689 NPI number — MICHIGAN STREET OPTICAL

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 1043350689 NPI number — MICHIGAN STREET OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN STREET 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:
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:
1043350689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2588
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49081-2588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-373-8878
Provider Business Mailing Address Fax Number:
269-373-4720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 MICHIGAN ST NE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-459-1844
Provider Business Practice Location Address Fax Number:
616-459-3716
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENNINGER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-373-8878

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  4301030073 , 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: 540D116620 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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