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General NPI Number Information
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NPI Number | 1700952975
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Entity Type | Organization
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Legal Business Name | CUSTOM EYE PROSTHETICS INC
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 27600 HOOVER RD
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City | WARREN
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State | MI
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Zip | 48093-7721
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Country | US
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Telephone | 586-755-6900
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Fax | 586-755-8026
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Provider Business Mailing Address
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Address Line | 27600 HOOVER RD
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City | WARREN
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State | MI
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Zip | 48093-7721
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Country | US
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Telephone | 586-755-6900
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Fax | 586-755-8026
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Authorized Official
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Title or Position | OWNER
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Name | MR. TERRY ALLEN BULGARELLI SR.
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Credential | BCO BADO BOARD CERTI
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Telephone | 586-755-6900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1700X
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Taxonomy Name | Ocularist
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License Number | 5001000012
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License Number State | MI
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