Healthcare Provider Details

I. General information

NPI: 1295868602
Provider Name (Legal Business Name): MAC OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N LEROY ST
FENTON MI
48430-2763
US

IV. Provider business mailing address

1425 N. LEROY ST
FENTON MI
48430
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-2041
  • Fax: 810-629-9366
Mailing address:
  • Phone: 810-664-5929
  • Fax: 810-664-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMH003723
License Number StateMI

VIII. Authorized Official

Name: MICHAEL G HENDRICKS
Title or Position: OWNER
Credential:
Phone: 810-629-2041