Provider Demographics
NPI:1346761558
Name:FRYE'S NEW LOOK OPTICAL
Entity Type:Organization
Organization Name:FRYE'S NEW LOOK OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:CMCB
Authorized Official - Phone:248-219-9782
Mailing Address - Street 1:12897 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12897 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3315
Practice Address - Country:US
Practice Address - Phone:248-499-4516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1427585801Medicaid