Provider Demographics
NPI:1043350689
Name:MICHIGAN STREET OPTICAL
Entity Type:Organization
Organization Name:MICHIGAN STREET OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:BENNINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-373-8878
Mailing Address - Street 1:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2588
Mailing Address - Country:US
Mailing Address - Phone:269-373-8878
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:426 MICHIGAN ST NE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5609
Practice Address - Country:US
Practice Address - Phone:616-459-1844
Practice Address - Fax:616-459-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030073332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540D116620OtherBLUE CROSS BLUE SHEILD
MI5565650001Medicare NSC