=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801954565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET OPTOMETRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 02/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1245 E. MAIN ST.
-----------------------------------------------------
City | PINCKNEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48169-8133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-878-7444
-----------------------------------------------------
Fax | 734-878-0678
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1245 E. MAIN ST.
-----------------------------------------------------
City | PINCKNEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48169-8133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-878-7444
-----------------------------------------------------
Fax | 734-878-0678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RENEE LYNN LALIBERTE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 734-878-7444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901003882
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------