Healthcare Provider Details

I. General information

NPI: 1063406510
Provider Name (Legal Business Name): CLYSON, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 N WISNER ST
JACKSON MI
49202-3144
US

IV. Provider business mailing address

904 N WISNER ST
JACKSON MI
49202-3144
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-9388
  • Fax: 517-782-9018
Mailing address:
  • Phone: 517-782-9388
  • Fax: 517-782-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: RITA SWARTZLANDER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 517-782-9388