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General NPI Number Information
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NPI Number | 1013689819
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Entity Type | Organization
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Legal Business Name | VICKSBURG OPTOMETRY LLC
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Dates
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Enumeration Date | 09/30/2021
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Last Update Date | 09/30/2021
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Provider Practice Location Address
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Address Line | 800 E CHICAGO ST
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City | COLDWATER
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State | MI
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Zip | 49036-2055
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Country | US
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Telephone | 517-278-2809
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Fax | 517-278-2199
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Provider Business Mailing Address
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Address Line | 1333 ELLERY GROVE CT
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City | VICKSBURG
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State | MI
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Zip | 49097-7778
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Country | US
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Telephone | 269-268-5140
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST OWNER
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Name | MARIA LYN-SHOOP GARCIA
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Credential | OD
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Telephone | 269-649-0103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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