Provider Demographics
NPI:1720033343
Name:PCOR LLC
Entity Type:Organization
Organization Name:PCOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-588-9300
Mailing Address - Street 1:735 JOHN R RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5859
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:248-588-3355
Practice Address - Street 1:655 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1844
Practice Address - Country:US
Practice Address - Phone:248-577-3616
Practice Address - Fax:248-307-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU80751Medicare UPIN