=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235510892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSEN EYE PROSTHETICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 02/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4719 SAINT ANTOINE ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-249-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5649
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48603-0649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-249-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. GREGORY CARMEN HAZEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 989-249-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1700X
-----------------------------------------------------
Taxonomy Name | Ocularist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------