Healthcare Provider Details

I. General information

NPI: 1407058928
Provider Name (Legal Business Name): CUTTING EDGE EYEWEAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 COUNTY ROAD 633 SUITE B
GRAWN MI
49637-9450
US

IV. Provider business mailing address

1525 COUNTY ROAD 633 SUITE B
GRAWN MI
49637-9450
US

V. Phone/Fax

Practice location:
  • Phone: 231-943-4510
  • Fax: 231-943-8274
Mailing address:
  • Phone: 231-943-4510
  • Fax: 231-943-8274

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: MS. RAE M FREDENBURG
Title or Position: OWNER
Credential:
Phone: 231-943-4510