Basic Information
| Provider Information | |||||||||
| NPI: | 1316073992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EPPS | ||||||||
| FirstName: | TRAYCE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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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: | 16128 MIDDLEBELT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481543338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344212844 | ||||||||
| FaxNumber: | 7344212878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003338 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 4801681 | 05 | MI | MEDICAID |