Provider Demographics
NPI:1295031060
Name:RICHARD J. ST. LOUIS O.D. PLLC
Entity type:Organization
Organization Name:RICHARD J. ST. LOUIS O.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ST. LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-673-7601
Mailing Address - Street 1:4486 W WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4073
Mailing Address - Country:US
Mailing Address - Phone:248-673-7601
Mailing Address - Fax:248-673-1317
Practice Address - Street 1:4486 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4073
Practice Address - Country:US
Practice Address - Phone:248-673-7601
Practice Address - Fax:248-673-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002559332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3920Medicare PIN
MI6507310001Medicare NSC