Provider Demographics
NPI:1861513780
Name:SMALL MALL VISION CENTER
Entity type:Organization
Organization Name:SMALL MALL VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-743-2830
Mailing Address - Street 1:3600 S DORT HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2093
Mailing Address - Country:US
Mailing Address - Phone:810-743-2830
Mailing Address - Fax:810-743-1729
Practice Address - Street 1:3600 S DORT HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2093
Practice Address - Country:US
Practice Address - Phone:810-743-2830
Practice Address - Fax:810-743-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B565030OtherBCBS OF MI
MI0B565030OtherBCBS OF MI