Healthcare Provider Details

I. General information

NPI: 1568638914
Provider Name (Legal Business Name): PCOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4281 24TH AVE # ATE200
FORT GRATIOT MI
48059-3997
US

IV. Provider business mailing address

735 JOHN R RD STE 150
TROY MI
48083-5859
US

V. Phone/Fax

Practice location:
  • Phone: 810-385-4000
  • Fax:
Mailing address:
  • Phone: 248-588-9300
  • Fax: 248-307-9518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. GAIL A. ELIAS
Title or Position: VP
Credential:
Phone: 248-577-3624