Basic Information
| Provider Information | |||||||||
| NPI: | 1992792154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENNETT OPTOMETRY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENNETT OPTOMETRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346655306 | ||||||||
| FaxNumber: | 7349302383 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481041902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 7346655522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WACHTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6362004393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152WC0802X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WS0006X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Sports Vision | 152WV0400X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WX0102X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152W00000X | BME-0160973 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.