Provider Demographics
NPI:1295782720
Name:FLUSHING VISION CLINIC PC
Entity type:Organization
Organization Name:FLUSHING VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-659-3135
Mailing Address - Street 1:1379 FLUSHING RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2262
Mailing Address - Country:US
Mailing Address - Phone:810-659-3135
Mailing Address - Fax:810-659-0024
Practice Address - Street 1:1379 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2262
Practice Address - Country:US
Practice Address - Phone:810-659-3135
Practice Address - Fax:810-659-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B514120OtherBCBSM
MI0764850001Medicare NSC
MI900B514120OtherBCBSM