Provider Demographics
NPI:1801954565
Name:MAIN STREET OPTOMETRY, INC.
Entity type:Organization
Organization Name:MAIN STREET OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LALIBERTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-878-7444
Mailing Address - Street 1:1245 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-8133
Mailing Address - Country:US
Mailing Address - Phone:734-878-7444
Mailing Address - Fax:734-878-0678
Practice Address - Street 1:1245 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-8133
Practice Address - Country:US
Practice Address - Phone:734-878-7444
Practice Address - Fax:734-878-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N91200Medicare ID - Type Unspecified
MI5347270002Medicare NSC
MIU80025Medicare UPIN