Healthcare Provider Details

I. General information

NPI: 1235510892
Provider Name (Legal Business Name): ANDERSEN EYE PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4719 SAINT ANTOINE ST
DETROIT MI
48201-1423
US

IV. Provider business mailing address

PO BOX 5649
SAGINAW MI
48603-0649
US

V. Phone/Fax

Practice location:
  • Phone: 989-249-1030
  • Fax:
Mailing address:
  • Phone: 989-249-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY CARMEN HAZEN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 989-249-1030