Provider Demographics
NPI:1740665298
Name:BELLEVILLE-CANTON OPTOMETRY LLC
Entity type:Organization
Organization Name:BELLEVILLE-CANTON OPTOMETRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:LESNICK-QUISLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-844-0400
Mailing Address - Street 1:1675 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2948
Mailing Address - Country:US
Mailing Address - Phone:734-844-0400
Mailing Address - Fax:734-844-0403
Practice Address - Street 1:1675 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187
Practice Address - Country:US
Practice Address - Phone:734-844-0400
Practice Address - Fax:734-844-0403
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLEVILLE-CANTON OPTOMETRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-27
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801073119Medicaid