Provider Demographics
NPI:1700960416
Name:WALLACE OPTICIANS INC
Entity Type:Organization
Organization Name:WALLACE OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:517-332-8628
Mailing Address - Street 1:3040 VINE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912
Mailing Address - Country:US
Mailing Address - Phone:517-332-8628
Mailing Address - Fax:517-332-5504
Practice Address - Street 1:3040 VINE ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912
Practice Address - Country:US
Practice Address - Phone:517-332-8628
Practice Address - Fax:517-332-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C36325OtherBCBS
MI900C36325OtherBCBS