Provider Demographics
NPI:1669507935
Name:TERRIS FASHION OPTICAL LLC
Entity Type:Organization
Organization Name:TERRIS FASHION OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-932-0020
Mailing Address - Street 1:629 W CLOVERLAND DRIVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2045
Mailing Address - Country:US
Mailing Address - Phone:906-932-0020
Mailing Address - Fax:906-932-8057
Practice Address - Street 1:629 W CLOVERLAND DRIVE
Practice Address - Street 2:SUITE 7
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-2045
Practice Address - Country:US
Practice Address - Phone:906-932-0020
Practice Address - Fax:906-932-8057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38723900Medicaid
WI38723900Medicaid