MEDICARE: TUDHOPE OPTICAL COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901001807	MI
2	156FX1800X	Optician		MI
3	332H00000X	Eyewear Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0G40268	OTHER	MI	BCBS OF MI VISION PROV.
2	71062	OTHER	MI	HEALTH PLAN OF MICHIGAN

General Provider Information

NPI Number	:	1083743116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUDHOPE OPTICAL COMPANY

Provider Business Mailing Address
First Line	:	2840 PINE GROVE AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-1971
Country	:	US
Telephone Number	:	810-982-0614
Fax Number	:	810-982-0621

Provider Business Practice Location Address
First Line	:	2840 PINE GROVE AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-1971
Country	:	US
Telephone Number	:	810-982-0614
Fax Number	:	810-982-0621

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SUSAN MARY WIEGAND
Credential	:
Telephone Number	:	810-982-0614

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	11/09/2011

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Directions to “TUDHOPE OPTICAL COMPANY ” Practice Location

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