Provider Demographics
NPI:1841371556
Name:HIEMSTRA OPTICAL COMPANY
Entity type:Organization
Organization Name:HIEMSTRA OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:TOTZKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-657-7288
Mailing Address - Street 1:133 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1429
Mailing Address - Country:US
Mailing Address - Phone:269-657-7288
Mailing Address - Fax:269-655-9063
Practice Address - Street 1:133 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1429
Practice Address - Country:US
Practice Address - Phone:269-657-7288
Practice Address - Fax:269-655-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID #
MI1265230005Medicare NSC