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General NPI Number Information
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NPI Number | 1013915859
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Entity Type | Individual
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Provider Name | LARA ANN EENIGENBURG O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/13/2005
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Last Update Date | 05/21/2008
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Provider Practice Location Address
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Address Line | 103 S DIVISION AVE PO BOX E
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City | FREMONT
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State | MI
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Zip | 49412-1602
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Country | US
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Telephone | 231-924-4110
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Fax | 231-924-5007
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Provider Business Mailing Address
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Address Line | 103 S DIVISION AVE PO BOX E
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City | FREMONT
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State | MI
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Zip | 49412-1602
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Country | US
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Telephone | 231-924-4110
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Fax | 231-924-5007
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4901004195
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License Number State | MI
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