Provider Demographics
NPI:1801463716
Name:LUM, BRIAN RAY
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:RAY
Last Name:LUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2174 PALMS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MI
Mailing Address - Zip Code:48063-3904
Mailing Address - Country:US
Mailing Address - Phone:248-259-7407
Mailing Address - Fax:
Practice Address - Street 1:45211 HELM ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6023
Practice Address - Country:US
Practice Address - Phone:800-741-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3873156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist