Healthcare Provider Details

I. General information

NPI: 1215089230
Provider Name (Legal Business Name): DRS STEVEN AND BRENDA SMOKE OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 US HIGHWAY 12
NEW BUFFALO MI
49117-8848
US

IV. Provider business mailing address

18301 US HIGHWAY 12
NEW BUFFALO MI
49117-8848
US

V. Phone/Fax

Practice location:
  • Phone: 269-469-6331
  • Fax: 269-469-6848
Mailing address:
  • Phone: 269-469-6331
  • Fax: 269-469-6848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number04901003315
License Number StateMI

VIII. Authorized Official

Name: DR. BRENDA D SMOKE
Title or Position: VICE PRESIDENT
Credential: O.D.
Phone: 269-469-6331