1598075160 NPI number — DIRECT OPTICAL OF CANTON, LLC

Table of content: (NPI 1598075160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598075160 NPI number — DIRECT OPTICAL OF CANTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIRECT OPTICAL OF CANTON, LLC
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:
1598075160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41840 FORD ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-981-1760
Provider Business Mailing Address Fax Number:
734-981-1574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41840 FORD ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-981-1760
Provider Business Practice Location Address Fax Number:
734-981-1574
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MIHAJLOVSKI
Authorized Official First Name:
MARIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-981-1760

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NONE . This is a "DELTA VISION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "MECA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CP2724 . This is a "EYEMED VISION CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "MEBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 230266 . This is a "NATIONAL VISION ADMINISTRATORS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 900F376990 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "SUPERIOR VISION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 58695 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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