1093704850 NPI number — DELTAVISION OPTICAL CENTER PC

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 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".




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