Healthcare Provider Details

I. General information

NPI: 1518232040
Provider Name (Legal Business Name): ANDERSEN EYE PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2757 LEONARD ST NE STE 300
GRAND RAPIDS MI
49525-5807
US

IV. Provider business mailing address

5161 CARDINAL PARK DR
SAGINAW MI
48604-9435
US

V. Phone/Fax

Practice location:
  • Phone: 989-797-2400
  • Fax: 989-249-1035
Mailing address:
  • Phone: 989-797-2400
  • Fax: 989-249-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number5001000027
License Number StateMI

VIII. Authorized Official

Name: ALICIA O'CONNOR
Title or Position: CEO
Credential:
Phone: 989-341-7170