1669507935 NPI number — TERRIS FASHION OPTICAL LLC

Table of content: (NPI 1669507935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669507935 NPI number — TERRIS FASHION OPTICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRIS FASHION OPTICAL 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:
1669507935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
629 W CLOVERLAND DRIVE
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
IRONWOOD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49938-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-932-0020
Provider Business Mailing Address Fax Number:
906-932-8057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 W CLOVERLAND DRIVE
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
IRONWOOD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49938-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-932-0020
Provider Business Practice Location Address Fax Number:
906-932-8057
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBALL
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER OPTICIAN
Authorized Official Telephone Number:
906-932-0020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  1 , 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: 38723900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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