Healthcare Provider Details

I. General information

NPI: 1629012489
Provider Name (Legal Business Name): LO OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 JORDAN LAKE ST
LAKE ODESSA MI
48849-1212
US

IV. Provider business mailing address

1005 CHARLEVOIX DR STE 100
GRAND LEDGE MI
48837-8186
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-3284
  • Fax: 616-374-2020
Mailing address:
  • Phone: 517-337-1668
  • Fax: 517-622-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DONALD SHOOK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 517-337-1899