=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871788562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P-COR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2007
-----------------------------------------------------
Last Update Date | 01/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 N TELEGRAPH RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-243-2020
-----------------------------------------------------
Fax | 734-243-4567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 735 JOHN R RD STE 150
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-5859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-588-9300
-----------------------------------------------------
Fax | 734-243-4567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MRS. GAIL A. ELIAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-577-3624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901003915
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------