Provider Demographics
NPI:1013197326
Name:DONOVAN CONTACT LENS CO INC
Entity Type:Organization
Organization Name:DONOVAN CONTACT LENS CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCULARIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:734-425-3430
Mailing Address - Street 1:33612 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1540
Mailing Address - Country:US
Mailing Address - Phone:734-425-3430
Mailing Address - Fax:734-425-8090
Practice Address - Street 1:33612 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1540
Practice Address - Country:US
Practice Address - Phone:734-425-3430
Practice Address - Fax:734-425-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5001000008332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5090486Medicaid
MI71020000Q20959OtherBLUECROSS
MI5090486Medicaid