Healthcare Provider Details

I. General information

NPI: 1275127342
Provider Name (Legal Business Name): P-COR,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E MICHIGAN AVE STE 1110
JACKSON MI
49201-1498
US

IV. Provider business mailing address

735 JOHN R RD STE 150
TROY MI
48083-5859
US

V. Phone/Fax

Practice location:
  • Phone: 248-588-9300
  • Fax: 248-588-3355
Mailing address:
  • Phone: 248-588-9300
  • Fax: 248-588-9917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHAKIA TISDALE
Title or Position: CREDENTIALING & PRIVILEGING
Credential:
Phone: 248-577-3659