Provider Demographics
NPI:1952443293
Name:DAVISON VISION CENTER LLC
Entity Type:Organization
Organization Name:DAVISON VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CORIASSO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-653-4800
Mailing Address - Street 1:1097 S STATE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1934
Mailing Address - Country:US
Mailing Address - Phone:810-653-4800
Mailing Address - Fax:810-412-4124
Practice Address - Street 1:1097 S STATE RD
Practice Address - Street 2:STE 1
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1934
Practice Address - Country:US
Practice Address - Phone:810-653-4800
Practice Address - Fax:810-412-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B51565OtherBCBSM
MI900B51565OtherBCBSM