Provider Demographics
NPI:1811095680
Name:GOODRICH OPTICAL INC
Entity type:Organization
Organization Name:GOODRICH OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:ABOM
Authorized Official - Phone:517-393-2660
Mailing Address - Street 1:2450 DELHI COMMERCE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-2193
Mailing Address - Country:US
Mailing Address - Phone:517-393-2660
Mailing Address - Fax:517-393-1313
Practice Address - Street 1:6425 S PENNSYLVANIA AVE STE 13
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5975
Practice Address - Country:US
Practice Address - Phone:517-393-2660
Practice Address - Fax:517-393-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI22-00278OtherPHYSICIANS HEALTH PLAN
MI22-70051OtherPHP FAMILY CARE
MI900C313260OtherBLUE CROSS OF MICHIGAN
MIOP0850OtherEYEMED
MI900C313260OtherBLUE CROSS OF MICHIGAN