Healthcare Provider Details

I. General information

NPI: 1154619286
Provider Name (Legal Business Name): BRIAN M HALES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N MCEWAN ST # B
CLARE MI
48617-1196
US

IV. Provider business mailing address

1520 N MCEWAN ST # B
CLARE MI
48617-1196
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-2020
  • Fax: 989-386-7308
Mailing address:
  • Phone: 989-386-2020
  • Fax: 989-386-7308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004640
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: