Healthcare Provider Details

I. General information

NPI: 1881012011
Provider Name (Legal Business Name): HOLLY VISION SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 N SAGINAW ST 1
HOLLY MI
48442-1380
US

IV. Provider business mailing address

1379 FLUSHING RD
FLUSHING MI
48433-2262
US

V. Phone/Fax

Practice location:
  • Phone: 810-659-3135
  • Fax:
Mailing address:
  • Phone: 810-659-3135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MS. REBECCA WALLACE
Title or Position: OFFICE MANAGER
Credential:
Phone: 810-659-3135