Healthcare Provider Details

I. General information

NPI: 1578535126
Provider Name (Legal Business Name): ADVANCED OPTOMETRY, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PALUSTER ST
CADILLAC MI
49601-2532
US

IV. Provider business mailing address

120 PALUSTER ST
CADILLAC MI
49601-2532
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-7341
  • Fax: 231-775-3925
Mailing address:
  • Phone: 231-775-7341
  • Fax: 231-775-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002495
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL E. MYERS
Title or Position: MEMBER PLLC
Credential: O.D.
Phone: 231-775-7341