Healthcare Provider Details

I. General information

NPI: 1265006522
Provider Name (Legal Business Name): ASHLEY MARIE WESLEY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E FRONT ST STE A
BUCHANAN MI
49107-1403
US

IV. Provider business mailing address

1381 W GLENLORD RD
SAINT JOSEPH MI
49085-9575
US

V. Phone/Fax

Practice location:
  • Phone: 269-695-3434
  • Fax:
Mailing address:
  • Phone: 248-892-0051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005550
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: