Healthcare Provider Details

I. General information

NPI: 1821061714
Provider Name (Legal Business Name): GRAHAM'S OPTIQUE BOUTIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20100 OUTER DR
DEARBORN MI
48124-2647
US

IV. Provider business mailing address

20100 OUTER DRIVE
DEARBORN MI
48124-2920
US

V. Phone/Fax

Practice location:
  • Phone: 313-562-0001
  • Fax: 313-562-4840
Mailing address:
  • Phone: 313-562-0001
  • Fax: 313-562-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH L DEROSE
Title or Position: OPTICAN
Credential: OPTICAN
Phone: 313-562-0001