Healthcare Provider Details

I. General information

NPI: 1942887039
Provider Name (Legal Business Name): P-COR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E. 2ND STREET
ROYAL OAK MI
48067
US

IV. Provider business mailing address

735 JOHN R RD STE 150
TROY MI
48083-5859
US

V. Phone/Fax

Practice location:
  • Phone: 248-951-0100
  • Fax: 248-951-0101
Mailing address:
  • Phone: 248-588-9300
  • Fax: 248-781-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SHAKIA TISDALE
Title or Position: CREDENTIALING & PRIVILEGING
Credential:
Phone: 248-577-3659