Basic Information
| Provider Information | |||||||||
| NPI: | 1164557146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SVS VISION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SVS VISION 13 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 MACOMB PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480435651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
| FaxNumber: | 5864687682 | ||||||||
| Practice Location | |||||||||
| Address1: | 30120 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480821611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867787542 | ||||||||
| FaxNumber: | 5867781849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5864687370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| 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 | 4500445 | 05 | MI | MEDICAID |