Provider Demographics
NPI:1851594246
Name:ERROL R CONGLETON OD PC
Entity Type:Organization
Organization Name:ERROL R CONGLETON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERROL
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:CONGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-835-2020
Mailing Address - Street 1:509 S SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4516
Mailing Address - Country:US
Mailing Address - Phone:989-835-2020
Mailing Address - Fax:989-835-6192
Practice Address - Street 1:509 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4516
Practice Address - Country:US
Practice Address - Phone:989-835-2020
Practice Address - Fax:989-835-6192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0822840001Medicare NSC
MI0P44530Medicare PIN