Healthcare Provider Details

I. General information

NPI: 1336556893
Provider Name (Legal Business Name): TOM LAVERN HALL II OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 E GRAND RIVER AVE
FOWLERVILLE MI
48836
US

IV. Provider business mailing address

136 E GRAND RIVER AVE
FOWLERVILLE MI
48836-5136
US

V. Phone/Fax

Practice location:
  • Phone: 517-223-9988
  • Fax: 517-223-9071
Mailing address:
  • Phone: 517-223-9988
  • Fax: 517-223-9071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4901004859
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901004859
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: