Healthcare Provider Details

I. General information

NPI: 1154322956
Provider Name (Legal Business Name): TERESA MARIE ENNIS-DECKER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

9575 STATE RD
MILLINGTON MI
48746-9482
US

IV. Provider business mailing address

9575 STATE RD
MILLINGTON MI
48746-9482
US

V. Phone/Fax

Practice location:
  • Phone: 989-871-9552
  • Fax: 989-871-9554
Mailing address:
  • Phone: 989-871-9552
  • Fax: 989-871-9554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003316
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: