Healthcare Provider Details

I. General information

NPI: 1366833865
Provider Name (Legal Business Name): BRANDY PETERSON A.B.O.C., N.C.L.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18511 SOUTH RIVER RD,
THREE RIVERS MI
49093
US

IV. Provider business mailing address

18511 SOUTH RIVER RD,
THREE RIVERS MI
49093
US

V. Phone/Fax

Practice location:
  • Phone: 734-657-7543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number156379
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number156379
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: