Healthcare Provider Details

I. General information

NPI: 1073572962
Provider Name (Legal Business Name): MEDICAL VILLAGE OPTICAL SHOPPE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD SUITE 12
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

31815 SOUTHFIELD RD SUITE 12
BEVERLY HILLS MI
48025-5471
US

V. Phone/Fax

Practice location:
  • Phone: 248-645-2220
  • Fax: 877-547-8277
Mailing address:
  • Phone: 248-645-2220
  • Fax: 877-547-8277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002468
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROY KNOERR
Title or Position: CEO
Credential:
Phone: 248-645-2220