MEDICARE: EYE 2 EYE CONTACT

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	156FX1800X	Optician	151016	MI

General Provider Information

NPI Number	:	1689014573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE 2 EYE CONTACT

Provider Business Mailing Address
First Line	:	723 RIVER PARK VILLAGE BLVD
Second Line	:	MOBILE UNIT DISPENSARY
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-2777
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	723 RIVER PARK VILLAGE BLVD
Second Line	:	MOBILE UNIT DISPENSARY
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-2777
Country	:	US
Telephone Number	:	313-378-7883
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN
Name	:	WILLIE DARE TAYLOR
Credential	:	ABOC,NCLEC,MBOC
Telephone Number	:	313-378-7883

Provider Enumeration Date	:	06/25/2013
Last Update Date	:	06/25/2013

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