Provider Demographics
NPI:1871027409
Name:EYEWEAR DETROIT
Entity Type:Organization
Organization Name:EYEWEAR DETROIT
Other - Org Name:SHELBY EYECARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMARCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:586-739-9550
Mailing Address - Street 1:6466 SHAPPIE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-1960
Mailing Address - Country:US
Mailing Address - Phone:248-396-2214
Mailing Address - Fax:
Practice Address - Street 1:48187 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-3268
Practice Address - Country:US
Practice Address - Phone:586-739-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004205152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOPO1800Medicare UPIN