Provider Demographics
NPI:1619271996
Name:FERRIS OPTICAL CORP
Entity Type:Organization
Organization Name:FERRIS OPTICAL CORP
Other - Org Name:DBA LONGE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER - PRESIDENT - OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-789-6171
Mailing Address - Street 1:900 E GANSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1700
Mailing Address - Country:US
Mailing Address - Phone:517-789-6171
Mailing Address - Fax:517-789-6200
Practice Address - Street 1:900 E GANSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1700
Practice Address - Country:US
Practice Address - Phone:517-789-6171
Practice Address - Fax:517-789-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945036409Medicaid
MIU33668Medicare UPIN
MI945036409Medicaid