1104942135 NPI number — TAWAS BAY OPTICAL INC.

Table of content: (NPI 1104942135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104942135 NPI number — TAWAS BAY OPTICAL INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAWAS BAY OPTICAL INC.
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:
1104942135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1691 N US 23
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
EAST TAWAS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-362-9546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1691 N US 23
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
EAST TAWAS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-362-9546
Provider Business Practice Location Address Fax Number:
989-362-9567
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-362-9546

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003153 , 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: 900C510060 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 410046393 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0M89210001 . This is a "BCBSM MEDICARE ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1291550002 . This is a "DMERC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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