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General NPI Number Information
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NPI Number | 1750664991
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Entity Type | Organization
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Legal Business Name | FENTON VISION SENSORY AND LEARNING CENTER PLLC
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Dates
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Enumeration Date | 09/23/2011
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Last Update Date | 09/23/2011
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Provider Practice Location Address
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Address Line | 1535 N LEROY ST SUITE D
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City | FENTON
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State | MI
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Zip | 48430-2791
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Country | US
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Telephone | 810-629-3070
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Fax |
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Provider Business Mailing Address
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Address Line | 745 1ST ST
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City | FENTON
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State | MI
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Zip | 48430-4103
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Country | US
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Telephone | 810-629-3070
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CYNTHIA LOUISE CUPAL
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Credential | O.D.
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Telephone | 810-629-3070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 4901002996
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License Number State | MI
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