Provider Demographics
NPI:1457600207
Name:MATTICE-BOBER, JANIECE LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JANIECE
Middle Name:LYNN
Last Name:MATTICE-BOBER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JANIECE
Other - Middle Name:LYNN
Other - Last Name:MATTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5608 LINTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4704
Mailing Address - Country:US
Mailing Address - Phone:231-282-3044
Mailing Address - Fax:
Practice Address - Street 1:6523 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3066
Practice Address - Country:US
Practice Address - Phone:231-282-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist