Healthcare Provider Details

I. General information

NPI: 1215667357
Provider Name (Legal Business Name): OSCODA OPTICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 E US 23 STE 2
EAST TAWAS MI
48730-9337
US

IV. Provider business mailing address

1691 E US 23 STE 2
EAST TAWAS MI
48730-9337
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-9546
  • Fax: 989-362-9567
Mailing address:
  • Phone: 989-362-9546
  • Fax: 989-362-9567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. CRYSTAL RUEMENAPP
Title or Position: PRESIDENT
Credential: OD
Phone: 989-362-9546