Healthcare Provider Details

I. General information

NPI: 1558346155
Provider Name (Legal Business Name): RENEE LYNN LALIBERTE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8089 MAIN ST SUITE 1
DEXTER MI
48130-1079
US

IV. Provider business mailing address

8089 MAIN ST SUITE 1
DEXTER MI
48130-1079
US

V. Phone/Fax

Practice location:
  • Phone: 734-424-9230
  • Fax:
Mailing address:
  • Phone: 734-424-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: