Provider Demographics
NPI:1750664991
Name:FENTON VISION SENSORY AND LEARNING CENTER PLLC
Entity Type:Organization
Organization Name:FENTON VISION SENSORY AND LEARNING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CUPAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-629-3070
Mailing Address - Street 1:745 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-4103
Mailing Address - Country:US
Mailing Address - Phone:810-629-3070
Mailing Address - Fax:
Practice Address - Street 1:1535 N LEROY ST
Practice Address - Street 2:SUITE D
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2791
Practice Address - Country:US
Practice Address - Phone:810-629-3070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002996261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty