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General NPI Number Information
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NPI Number | 1104571074
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Entity Type | Organization
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Legal Business Name | P-COR LLC
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Dates
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Enumeration Date | 02/18/2022
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Last Update Date | 02/18/2022
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Provider Practice Location Address
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Address Line | 40895 ANN ARBOR RD
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City | PLYMOUTH
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State | MI
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Zip | 48170
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Country | US
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Telephone | 734-233-6300
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Fax |
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Provider Business Mailing Address
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Address Line | 735 JOHN R RD STE 150
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City | TROY
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State | MI
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Zip | 48083-5859
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Country | US
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Telephone | 248-588-9300
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING/PRIVILEGING
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Name | SHAKIA TISDALE
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Credential |
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Telephone | 248-577-3659
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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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