Basic Information
| Provider Information | |||||||||
| NPI: | 1740665298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEVILLE-CANTON OPTOMETRY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISIONPRO EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 N CANTON CENTER RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481872948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348440400 | ||||||||
| FaxNumber: | 7348440403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 N CANTON CENTER RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348440400 | ||||||||
| FaxNumber: | 7348440403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | LESNICK-QUISLING | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7348440400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BELLEVILLE-CANTON OPTOMETRY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1801073119 | 05 | MI | MEDICAID |