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General NPI Number Information
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NPI Number | 1073572962
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Entity Type | Organization
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Legal Business Name | MEDICAL VILLAGE OPTICAL SHOPPE INC
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Dates
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Enumeration Date | 03/21/2006
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Last Update Date | 05/17/2016
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Provider Practice Location Address
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Address Line | 31815 SOUTHFIELD RD SUITE 12
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City | BEVERLY HILLS
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State | MI
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Zip | 48025-5471
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Country | US
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Telephone | 248-645-2220
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Fax | 877-547-8277
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Provider Business Mailing Address
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Address Line | 31815 SOUTHFIELD RD SUITE 12
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City | BEVERLY HILLS
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State | MI
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Zip | 48025-5471
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Country | US
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Telephone | 248-645-2220
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Fax | 877-547-8277
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Authorized Official
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Title or Position | CEO
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Name | MR. ROY KNOERR
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Credential |
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Telephone | 248-645-2220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901002468
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License Number State | MI
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