Provider Demographics
NPI:1114103140
Name:NORTHSHORE OPTOMETRY LLC
Entity Type:Organization
Organization Name:NORTHSHORE OPTOMETRY LLC
Other - Org Name:KORINNE SWAIN, O.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KORINNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-744-3573
Mailing Address - Street 1:1179 WHITEHALL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:N MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2497
Mailing Address - Country:US
Mailing Address - Phone:231-744-3573
Mailing Address - Fax:
Practice Address - Street 1:1179 WHITEHALL RD
Practice Address - Street 2:SUITE B
Practice Address - City:N MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-2497
Practice Address - Country:US
Practice Address - Phone:231-744-3573
Practice Address - Fax:231-719-9016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI49010003090305S00000X
MI4901003090332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1806648Medicaid
MI1806648Medicaid
MIU27341Medicare UPIN