Healthcare Provider Details

I. General information

NPI: 1659685576
Provider Name (Legal Business Name): PCOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 25 MILE RD
SHELBY TOWNSHIP MI
48316-0941
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-651-3937
  • Fax:
Mailing address:
  • Phone: 248-588-9300
  • Fax: 248-588-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004068
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. GAIL ELIAS
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 248-577-3624