Provider Demographics
NPI:1073832846
Name:CHERRY OPTOMETRY, P.C.
Entity Type:Organization
Organization Name:CHERRY OPTOMETRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-475-3800
Mailing Address - Street 1:314 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1280
Mailing Address - Country:US
Mailing Address - Phone:734-475-3800
Mailing Address - Fax:734-475-3821
Practice Address - Street 1:314 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1280
Practice Address - Country:US
Practice Address - Phone:734-475-3800
Practice Address - Fax:734-475-3821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6183950001Medicare NSC