Basic Information
| Provider Information | |||||||||
| NPI: | 1801073119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLEVILLE-CANTON OPTOMERTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BELLEVILLE VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10798 BELLEVILLE RD. | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481111308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346976671 | ||||||||
| FaxNumber: | 7346979332 | ||||||||
| Practice Location | |||||||||
| Address1: | 10798 BELLEVILLE RD. | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481111308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346976671 | ||||||||
| FaxNumber: | 7346979332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | LESNICK | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7346976671 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002596 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.