Provider Demographics
NPI:1568508398
Name:NATIONAL EYEWEAR OUTLET OF WARREN
Entity Type:Organization
Organization Name:NATIONAL EYEWEAR OUTLET OF WARREN
Other - Org Name:NATIONAL DISCOUNT EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT-OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-558-3059
Mailing Address - Street 1:3200 E 12 MILE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5621
Mailing Address - Country:US
Mailing Address - Phone:586-558-3059
Mailing Address - Fax:586-558-3067
Practice Address - Street 1:3200 E 12 MILE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5621
Practice Address - Country:US
Practice Address - Phone:586-558-3059
Practice Address - Fax:586-558-3067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP1348OtherEYEMED GARY
MI147096OtherCOLE MANAGED VISION
MIMI2556OtherEYEMED DR
MIOP1347OtherEYEMED SHERRIE
MI233194OtherNVA
MICP1749OtherEYEMED LOCATION
MI233194OtherNVA