Healthcare Provider Details

I. General information

NPI: 1821001389
Provider Name (Legal Business Name): LORI ANN SMOLINSKI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI ANN MASTALANSKI O.D.

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 CHERRY ST SE
GRAND RAPIDS MI
49503-4626
US

IV. Provider business mailing address

42 COUNTRY CLUB RD
HOLLAND MI
49423-6605
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-1187
  • Fax: 616-458-7113
Mailing address:
  • Phone: 616-403-2990
  • Fax: 616-458-7113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number4901004066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: