Provider Demographics
NPI:1629252598
Name:SHORELINE OPTICAL, LLC
Entity Type:Organization
Organization Name:SHORELINE OPTICAL, LLC
Other - Org Name:SHORELINE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-739-9009
Mailing Address - Street 1:1266 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1847
Mailing Address - Country:US
Mailing Address - Phone:231-739-9009
Mailing Address - Fax:231-733-0566
Practice Address - Street 1:301 CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3104
Practice Address - Country:US
Practice Address - Phone:231-744-4580
Practice Address - Fax:231-744-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier