Healthcare Provider Details

I. General information

NPI: 1013120641
Provider Name (Legal Business Name): TLC LASER CENTER OF DETROIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34405 W 12 MILE RD STE. 154
FARMINGTON HILLS MI
48331-3391
US

IV. Provider business mailing address

16305 SWINGLEY RIDGE RD STE. 300
CHESTERFIELD MO
63017-1777
US

V. Phone/Fax

Practice location:
  • Phone: 248-489-0400
  • Fax:
Mailing address:
  • Phone: 636-534-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRISH MUNSELL
Title or Position: PARALEGAL
Credential:
Phone: 636-534-2300