Provider Demographics
NPI:1669535076
Name:SHORE OPTICAL
Entity type:Organization
Organization Name:SHORE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-294-3080
Mailing Address - Street 1:31503 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-2455
Mailing Address - Country:US
Mailing Address - Phone:586-294-3080
Mailing Address - Fax:586-294-8979
Practice Address - Street 1:31503 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2455
Practice Address - Country:US
Practice Address - Phone:586-294-3080
Practice Address - Fax:586-294-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5408160001Medicare NSC
MI0P17690Medicare ID - Type UnspecifiedMEDICARE PART B