1114354107 NPI number — OPTICAL GALLERY, INC.

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 1114354107 NPI number — OPTICAL GALLERY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTICAL GALLERY, 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:
1114354107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39400 GARFIELD RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-4096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-792-7320
Provider Business Mailing Address Fax Number:
586-792-7515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39400 GARFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-4096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-792-7320
Provider Business Practice Location Address Fax Number:
586-792-7515
Provider Enumeration Date:
10/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DEBEUL
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OPTICIAN
Authorized Official Telephone Number:
586-792-7320

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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