Healthcare Provider Details

I. General information

NPI: 1679721120
Provider Name (Legal Business Name): FRIENDS OF VISION INTERPERSONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 NORTHLAND PARK CT
SOUTHFIELD MI
48075-4324
US

IV. Provider business mailing address

5390 CAMBOURNE PL
WEST BLOOMFIELD MI
48322-4101
US

V. Phone/Fax

Practice location:
  • Phone: 248-757-2098
  • Fax: 248-757-2098
Mailing address:
  • Phone: 313-258-2086
  • Fax: 248-757-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. CONSTANCE GWYNN
Title or Position: FOUNDER/DIRECTOR
Credential: MSW
Phone: 313-258-2086