Provider Demographics
NPI:1942357652
Name:TRI STATE OPTICAL, INC.
Entity Type:Organization
Organization Name:TRI STATE OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:517-279-7951
Mailing Address - Street 1:350 MARSHALL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1175
Mailing Address - Country:US
Mailing Address - Phone:517-279-7951
Mailing Address - Fax:517-279-8000
Practice Address - Street 1:350 MARSHALL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1175
Practice Address - Country:US
Practice Address - Phone:517-279-7951
Practice Address - Fax:517-279-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4529069Medicaid