Provider Demographics
NPI:1598075160
Name:DIRECT OPTICAL OF CANTON, LLC
Entity Type:Organization
Organization Name:DIRECT OPTICAL OF CANTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIHAJLOVSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-981-1760
Mailing Address - Street 1:41840 FORD ROAD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187
Mailing Address - Country:US
Mailing Address - Phone:734-981-1760
Mailing Address - Fax:734-981-1574
Practice Address - Street 1:41840 FORD ROAD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187
Practice Address - Country:US
Practice Address - Phone:734-981-1760
Practice Address - Fax:734-981-1574
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIRECT OPTICAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINONEOtherDELTA VISION
INNONEOtherMECA
OHCP2724OtherEYEMED VISION CARE
MINONEOtherMEBS
NJ230266OtherNATIONAL VISION ADMINISTRATORS
MI900F376990OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MANONEOtherSUPERIOR VISION
NY58695OtherDAVIS VISION