Provider Demographics
NPI:1073572962
Name:MEDICAL VILLAGE OPTICAL SHOPPE INC
Entity Type:Organization
Organization Name:MEDICAL VILLAGE OPTICAL SHOPPE INC
Other - Org Name:MEDICAL VILLAGE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-645-2220
Mailing Address - Street 1:31815 SOUTHFIELD RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-645-2220
Mailing Address - Fax:877-547-8277
Practice Address - Street 1:31815 SOUTHFIELD RD
Practice Address - Street 2:SUITE 12
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-645-2220
Practice Address - Fax:877-547-8277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002468152W00000X
156FX1800X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1953840Medicaid
MION80960Medicare PIN
MI0750820001Medicare NSC