Healthcare Provider Details

I. General information

NPI: 1043350689
Provider Name (Legal Business Name): MICHIGAN STREET OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 MICHIGAN ST NE SUITE 101
GRAND RAPIDS MI
49503-5609
US

IV. Provider business mailing address

PO BOX 2588
PORTAGE MI
49081-2588
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-1844
  • Fax: 616-459-3716
Mailing address:
  • Phone: 269-373-8878
  • Fax: 269-373-4720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4301030073
License Number StateMI

VIII. Authorized Official

Name: DR. RICHARD H BENNINGER
Title or Position: OWNER
Credential: MD
Phone: 269-373-8878