Healthcare Provider Details

I. General information

NPI: 1205266061
Provider Name (Legal Business Name): L & B OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19216 FORT ST
RIVERVIEW MI
48193-6702
US

IV. Provider business mailing address

19216 FORT ST
RIVERVIEW MI
48193-6702
US

V. Phone/Fax

Practice location:
  • Phone: 734-479-5300
  • Fax: 734-479-5367
Mailing address:
  • Phone: 734-479-5300
  • Fax: 734-479-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT DEEK
Title or Position: PRESIDENT
Credential: OPTOMETRIST
Phone: 734-479-5300