1114052925 NPI number — SVS VISION INC

Table of content: (NPI 1114052925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114052925 NPI number — SVS VISION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SVS VISION 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:
6
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:
1114052925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 CASS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CLEMENS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48043-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-468-7370
Provider Business Mailing Address Fax Number:
586-468-7682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20330 WEST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODHAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48183-3321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-675-8197
Provider Business Practice Location Address Fax Number:
734-675-8289
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FARRELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
586-468-7370

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4500418 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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