Provider Demographics
NPI:1770885030
Name:ANN LACROIX FREDAL O.D. PLLC
Entity type:Organization
Organization Name:ANN LACROIX FREDAL O.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SZCZEPANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:586-468-4211
Mailing Address - Street 1:136 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2230
Mailing Address - Country:US
Mailing Address - Phone:586-468-4211
Mailing Address - Fax:586-468-6194
Practice Address - Street 1:136 CASS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2230
Practice Address - Country:US
Practice Address - Phone:586-468-4211
Practice Address - Fax:586-468-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002973332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4007510001OtherMEDICARE DME
MI4007510001OtherMEDICARE DME