Healthcare Provider Details

I. General information

NPI: 1417070392
Provider Name (Legal Business Name): FAMILY OPTOMETRY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 07/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26771 W 12 MILE RD SUITE 100
SOUTHFIELD MI
48034-1539
US

IV. Provider business mailing address

26771 W 12 MILE RD SUITE 100
SOUTHFIELD MI
48034-1539
US

V. Phone/Fax

Practice location:
  • Phone: 248-263-4900
  • Fax: 248-263-4903
Mailing address:
  • Phone: 248-263-4900
  • Fax: 248-263-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4901002652
License Number StateMI

VIII. Authorized Official

Name: DR. WILLIAM JERRY LINDAHL
Title or Position: PRESIDENT
Credential: O.D.
Phone: 248-263-4900