Healthcare Provider Details

I. General information

NPI: 1740464775
Provider Name (Legal Business Name): SOUTHLAND EYE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15055 S PLAZA DR
TAYLOR MI
48180-5202
US

IV. Provider business mailing address

15055 S PLAZA DR
TAYLOR MI
48180-5202
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-2666
  • Fax: 734-287-3864
Mailing address:
  • Phone: 734-287-2666
  • Fax: 734-287-3864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301034114
License Number StateMI

VIII. Authorized Official

Name: DR. MARILYN K. BELAMARIC
Title or Position: OWNER/DIRECTOR
Credential: M.D.
Phone: 734-287-2666