Healthcare Provider Details

I. General information

NPI: 1316338007
Provider Name (Legal Business Name): OWOSSO EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N WASHINGTON ST
OWOSSO MI
48867-2827
US

IV. Provider business mailing address

122 N WASHINGTON ST
OWOSSO MI
48867-2827
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-8174
  • Fax: 989-725-3123
Mailing address:
  • Phone: 989-723-8174
  • Fax: 989-725-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004859
License Number StateMI

VIII. Authorized Official

Name: DR. TOM HALL II
Title or Position: OWNER
Credential: OD
Phone: 989-424-0442