Provider Demographics
NPI:1417070392
Name:FAMILY OPTOMETRY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:FAMILY OPTOMETRY ASSOCIATES, P.C.
Other - Org Name:FAMILY OPTOMETRY PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JERRY
Authorized Official - Last Name:LINDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-263-4900
Mailing Address - Street 1:26771 W 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1539
Mailing Address - Country:US
Mailing Address - Phone:248-263-4900
Mailing Address - Fax:248-263-4903
Practice Address - Street 1:26771 W 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1539
Practice Address - Country:US
Practice Address - Phone:248-263-4900
Practice Address - Fax:248-263-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2012-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002652332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0169990001Medicare NSC
MI0F36724Medicare PIN