Healthcare Provider Details

I. General information

NPI: 1316058860
Provider Name (Legal Business Name): MICHEL DALE LISTENBERGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 S SAINT JOSEPH AVE
NILES MI
49120-2846
US

IV. Provider business mailing address

1248 HUFF AVE
NILES MI
49120-9509
US

V. Phone/Fax

Practice location:
  • Phone: 269-683-4040
  • Fax: 269-683-7565
Mailing address:
  • Phone: 269-683-4040
  • Fax: 269-683-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002348
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: