Provider Demographics
NPI:1336179597
Name:DISTINCTIVE EYEWEAR, INC.
Entity Type:Organization
Organization Name:DISTINCTIVE EYEWEAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPOT
Authorized Official - Phone:810-329-9725
Mailing Address - Street 1:1280 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5368
Mailing Address - Country:US
Mailing Address - Phone:810-329-9725
Mailing Address - Fax:810-329-3491
Practice Address - Street 1:1280 S 9TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5368
Practice Address - Country:US
Practice Address - Phone:810-329-9725
Practice Address - Fax:810-329-3491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101422OtherGREAT LAKES HEALTH PLAN
MI13314OtherSPECTERA
MI900G467000OtherBLUE CROSS
MIMI2751OtherEYEMED
MIMI02751OtherVISION BENEFIT OF AMERICA
MI943020464Medicaid
MI12065OtherHEALTH PLAN OF MI
MI25289OtherNATIONAL VISION ADMIN.
MIGK490100OtherBLUE CROSS PIN #
MI145807OtherCOLE VISION DOCTOR #
MI146505OtherCOLE VISION LOCATION #
MI3020464Medicaid
MI3020464Medicaid