Provider Demographics
NPI:1750601258
Name:FOREST PLACE OPTICAL LLC
Entity type:Organization
Organization Name:FOREST PLACE OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:GETSCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-455-3340
Mailing Address - Street 1:550 FOREST AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1769
Mailing Address - Country:US
Mailing Address - Phone:734-455-3340
Mailing Address - Fax:734-455-1727
Practice Address - Street 1:550 FOREST AVE STE 12
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1769
Practice Address - Country:US
Practice Address - Phone:734-455-3340
Practice Address - Fax:734-455-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6581300001Medicare NSC