Healthcare Provider Details

I. General information

NPI: 1164562393
Provider Name (Legal Business Name): CYNTHIA M KACZMAREK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2942 E HIGHLAND RD
HIGHLAND MI
48356-2810
US

IV. Provider business mailing address

2942 E HIGHLAND RD
HIGHLAND MI
48356-2810
US

V. Phone/Fax

Practice location:
  • Phone: 248-887-4175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002311
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA M KACZMAREK
Title or Position: OWNER
Credential:
Phone: 248-887-4175