Healthcare Provider Details

I. General information

NPI: 1962580159
Provider Name (Legal Business Name): DR. MARK NOSS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 MUNSON AVE
TRAVERSE CITY MI
49686-3040
US

IV. Provider business mailing address

328 MUNSON AVE
TRAVERSE CITY MI
49686-3040
US

V. Phone/Fax

Practice location:
  • Phone: 231-946-8460
  • Fax: 231-946-8507
Mailing address:
  • Phone: 231-946-8460
  • Fax: 231-946-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002760
License Number StateMI

VIII. Authorized Official

Name: MARK DAVID NOSS
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 231-946-8460