Healthcare Provider Details

I. General information

NPI: 1902998099
Provider Name (Legal Business Name): GRAND BLANC EYES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 S SAGINAW ST
GRAND BLANC MI
48439-1285
US

IV. Provider business mailing address

11225 S SAGINAW ST SUITE 10
GRAND BLANC MI
48439-1285
US

V. Phone/Fax

Practice location:
  • Phone: 810-694-3937
  • Fax: 810-694-9876
Mailing address:
  • Phone: 810-694-3937
  • Fax: 810-694-9876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW JOHN AGNONE
Title or Position: OWNER/MEMBER
Credential: O.D.
Phone: 810-694-3937