Healthcare Provider Details

I. General information

NPI: 1871788562
Provider Name (Legal Business Name): P-COR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N TELEGRAPH RD
MONROE MI
48162
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 734-243-2020
  • Fax: 734-243-4567
Mailing address:
  • Phone: 248-588-9300
  • Fax: 734-243-4567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003915
License Number StateMI

VIII. Authorized Official

Name: MRS. GAIL A. ELIAS
Title or Position: VP
Credential:
Phone: 248-577-3624