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General NPI Number Information
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NPI Number | 1831616754
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Entity Type | Organization
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Legal Business Name | CASEY COULTER PLLC
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Dates
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Enumeration Date | 08/23/2017
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Last Update Date | 08/23/2017
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Provider Practice Location Address
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Address Line | 4165 E COURT ST
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City | BURTON
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State | MI
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Zip | 48509-1717
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Country | US
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Telephone | 180-743-1286
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Fax |
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Provider Business Mailing Address
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Address Line | 9308 MEADOWVIEW DR
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City | DAVISON
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State | MI
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Zip | 48423
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | CASEY LEE COIULTER
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Credential | OD
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Telephone | 810-441-9007
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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 | 4901005064
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License Number State | MI
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