Basic Information
| Provider Information | |||||||||
| NPI: | 1497721799 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIRECT OPTICAL, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29321 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483342968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485538270 | ||||||||
| FaxNumber: | 2485538185 | ||||||||
| Practice Location | |||||||||
| Address1: | 29321 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483342968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485538270 | ||||||||
| FaxNumber: | 2485538185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHAIKEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | IRA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2485538270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 230266 | 01 | NATIONAL VISION ADMIN. | OTHER | 900F376990 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | CP2724 | 01 | EYE MED | OTHER | VC630014 | 01 | M-CARE | OTHER |