Healthcare Provider Details

I. General information

NPI: 1396929527
Provider Name (Legal Business Name): OWOSSO FAMILY OPTOMETRY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E MAIN ST
OWOSSO MI
48867-3136
US

IV. Provider business mailing address

311 E MAIN ST
OWOSSO MI
48867-3136
US

V. Phone/Fax

Practice location:
  • Phone: 989-725-2311
  • Fax: 989-725-6055
Mailing address:
  • Phone: 989-725-2311
  • Fax: 989-725-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2016491
License Number StateMI

VIII. Authorized Official

Name: DR. WALTER J LASOVAGE
Title or Position: OWNER
Credential: O.D.
Phone: 989-725-2311