Basic Information
| Provider Information | |||||||||
| NPI: | 1508130592 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SVS VISION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 MACOMB PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480435651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5761 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866193600 | ||||||||
| FaxNumber: | 5866193603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 05/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5864687370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
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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 | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 4500481 | 05 | MI | MEDICAID | MI1465 | 01 | MI | PTAN | OTHER |