Healthcare Provider Details

I. General information

NPI: 1902275944
Provider Name (Legal Business Name): IMLAY CITY OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W 3RD ST
IMLAY CITY MI
48444-1029
US

IV. Provider business mailing address

125 W 3RD ST
IMLAY CITY MI
48444-1029
US

V. Phone/Fax

Practice location:
  • Phone: 810-724-6155
  • Fax: 810-724-7708
Mailing address:
  • Phone: 810-724-6155
  • Fax: 810-724-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ARTHUR F WHALEY JR.
Title or Position: PRESIDENT
Credential:
Phone: 810-724-6155