Provider Demographics
NPI:1114114428
Name:MAC OPTICAL
Entity Type:Organization
Organization Name:MAC OPTICAL
Other - Org Name:DIAMOND OPTICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-887-4861
Mailing Address - Street 1:1425 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2763
Mailing Address - Country:US
Mailing Address - Phone:810-629-2041
Mailing Address - Fax:810-629-9366
Practice Address - Street 1:1425 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2763
Practice Address - Country:US
Practice Address - Phone:810-629-2041
Practice Address - Fax:810-629-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B51128OtherBLUE CROSS BLUE SHIELD
MI900B51128OtherBLUE CROSS BLUE SHIELD
MI0N11050OtherHAP
MI3442884Medicaid
MIU70329Medicare UPIN
MI900B51128OtherBLUE CROSS BLUE SHIELD
MI0N11050Medicare PIN