Provider Demographics
NPI:1790846533
Name:PROFESSIONAL OPTICAL LLC
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-0171
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE#204
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-487-0171
Mailing Address - Fax:231-487-0690
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE#204
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-0171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540B411030OtherMI BCBS
MI540B411030OtherMI BCBS