Healthcare Provider Details

I. General information

NPI: 1740519941
Provider Name (Legal Business Name): BENJAMIN SALVATORE MANIACI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35184 CENTRAL CITY PKWY
WESTLAND MI
48185-6215
US

IV. Provider business mailing address

655 W 13 MILE RD
MADISON HEIGHTS MI
48071-1850
US

V. Phone/Fax

Practice location:
  • Phone: 734-427-5200
  • Fax: 734-427-8136
Mailing address:
  • Phone: 248-577-3659
  • Fax: 248-588-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004519
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: