Basic Information
Provider Information | |||||||||
NPI: | 1114052172 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SVS VISION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SVS VISION 10 | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 118 CASS AVE | ||||||||
Address2: |   | ||||||||
City: | MOUNT CLEMENS | ||||||||
State: | MI | ||||||||
PostalCode: | 480432204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864687370 | ||||||||
FaxNumber: | 5864687682 | ||||||||
Practice Location | |||||||||
Address1: | 23055 COOLIDGE HWY | ||||||||
Address2: |   | ||||||||
City: | OAK PARK | ||||||||
State: | MI | ||||||||
PostalCode: | 482372071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483991556 | ||||||||
FaxNumber: | 2483992789 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 12/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FARRELL | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
AuthorizedOfficialTelephone: | 5864687370 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   | MI | N |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 4500490 | 05 | MI |   | MEDICAID |