Provider Demographics
NPI:1679660849
Name:BLACK AND WHITE LOOK OPTICAL CORPORATION
Entity Type:Organization
Organization Name:BLACK AND WHITE LOOK OPTICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-557-6444
Mailing Address - Street 1:15675 W TEN MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2188
Mailing Address - Country:US
Mailing Address - Phone:248-557-6444
Mailing Address - Fax:248-557-6501
Practice Address - Street 1:15675 W TEN MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2188
Practice Address - Country:US
Practice Address - Phone:248-557-6444
Practice Address - Fax:248-557-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3282118Medicaid
MI900F378590OtherBLUE CROSS PIN#
MA230892OtherNVA PIN#
MI024599OtherMIDWEST HEALTH PIN
MI113750OtherTOTAL HEALTH PIN#
MI6719OtherCO/OP PIN
MI0F37859OtherBLUE CROSS FEDERAL
MI024599OtherMIDWEST HEALTH PIN
MI0P25880Medicare PIN