Healthcare Provider Details

I. General information

NPI: 1780820423
Provider Name (Legal Business Name): STANISZEWSKI-PASQUA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 S OTSEGO AVE
GAYLORD MI
49735-1783
US

IV. Provider business mailing address

927 S OTSEGO AVE P.O. BOX 421
GAYLORD MI
49735-1783
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-7518
  • Fax: 989-732-4205
Mailing address:
  • Phone: 989-732-7518
  • Fax: 989-732-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LOIS J STANISZEWSKI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 989-724-7440