Provider Demographics
NPI:1689905929
Name:HERITAGE OPTICAL CENTER
Entity Type:Organization
Organization Name:HERITAGE OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-863-9581
Mailing Address - Street 1:19010 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2259
Mailing Address - Country:US
Mailing Address - Phone:313-863-9581
Mailing Address - Fax:
Practice Address - Street 1:87 MONROE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2855
Practice Address - Country:US
Practice Address - Phone:313-965-2740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2117Medicare PIN