Provider Demographics
NPI:1568536837
Name:OPTOMETRIC INSTITUTE AND CLINIC OF DETROIT, INC
Entity Type:Organization
Organization Name:OPTOMETRIC INSTITUTE AND CLINIC OF DETROIT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-872-2060
Mailing Address - Street 1:3044 W GRAND BLVD
Mailing Address - Street 2:SUITE L-350
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3037
Mailing Address - Country:US
Mailing Address - Phone:313-872-2060
Mailing Address - Fax:313-872-1020
Practice Address - Street 1:3044 W GRAND BLVD
Practice Address - Street 2:SUITE L-350
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3037
Practice Address - Country:US
Practice Address - Phone:313-872-2060
Practice Address - Fax:313-872-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5023750Medicaid
MI900H267920OtherBLUECROSS
MIU30652Medicare UPIN
MION39410Medicare ID - Type Unspecified