Provider Demographics
NPI:1700952975
Name:CUSTOM EYE PROSTHETICS INC
Entity Type:Organization
Organization Name:CUSTOM EYE PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BULGARELLI
Authorized Official - Suffix:SR
Authorized Official - Credentials:BCO BADO BOARD CERTI
Authorized Official - Phone:586-755-6900
Mailing Address - Street 1:27600 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7721
Mailing Address - Country:US
Mailing Address - Phone:586-755-6900
Mailing Address - Fax:586-755-8026
Practice Address - Street 1:27600 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7721
Practice Address - Country:US
Practice Address - Phone:586-755-6900
Practice Address - Fax:586-755-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5001000012156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0729810001Medicare ID - Type Unspecified