Provider Demographics
NPI:1740299940
Name:RANDALL J RIEMER, OD, PLC
Entity type:Organization
Organization Name:RANDALL J RIEMER, OD, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-647-2020
Mailing Address - Street 1:207 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1436
Mailing Address - Country:US
Mailing Address - Phone:517-647-2020
Mailing Address - Fax:517-647-7677
Practice Address - Street 1:207 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1436
Practice Address - Country:US
Practice Address - Phone:517-647-2020
Practice Address - Fax:517-647-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0137580001Medicare NSC