Provider Demographics
NPI:1407058928
Name:CUTTING EDGE EYEWEAR
Entity Type:Organization
Organization Name:CUTTING EDGE EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FREDENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-943-4510
Mailing Address - Street 1:1525 COUNTY ROAD 633
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAWN
Mailing Address - State:MI
Mailing Address - Zip Code:49637-9450
Mailing Address - Country:US
Mailing Address - Phone:231-943-4510
Mailing Address - Fax:231-943-8274
Practice Address - Street 1:1525 COUNTY ROAD 633
Practice Address - Street 2:SUITE B
Practice Address - City:GRAWN
Practice Address - State:MI
Practice Address - Zip Code:49637-9450
Practice Address - Country:US
Practice Address - Phone:231-943-4510
Practice Address - Fax:231-943-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4621718Medicaid