Provider Demographics
NPI:1013120641
Name:TLC LASER CENTER OF DETROIT, LLC
Entity Type:Organization
Organization Name:TLC LASER CENTER OF DETROIT, LLC
Other - Org Name:TLC LASER EYE CENTERS DETROIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARALEGAL
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-534-2300
Mailing Address - Street 1:16305 SWINGLEY RIDGE RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-1777
Mailing Address - Country:US
Mailing Address - Phone:636-534-2300
Mailing Address - Fax:
Practice Address - Street 1:34405 W 12 MILE RD
Practice Address - Street 2:STE. 154
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3391
Practice Address - Country:US
Practice Address - Phone:248-489-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TLC MICHIGAN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-08
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180F373640OtherBCBS MICHIGAN G2 QUAL