Healthcare Provider Details

I. General information

NPI: 1114103140
Provider Name (Legal Business Name): NORTHSHORE OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 WHITEHALL RD SUITE B
N MUSKEGON MI
49445-2497
US

IV. Provider business mailing address

1179 WHITEHALL RD SUITE B
N MUSKEGON MI
49445-2497
US

V. Phone/Fax

Practice location:
  • Phone: 231-744-3573
  • Fax: 231-719-9016
Mailing address:
  • Phone: 231-744-3573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4901003090
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number49010003090
License Number StateMI

VIII. Authorized Official

Name: DR. KORINNE MARIE SWAIN
Title or Position: OWNER
Credential: O.D.
Phone: 231-744-3573