Provider Demographics
NPI:1104942135
Name:TAWAS BAY OPTICAL INC.
Entity type:Organization
Organization Name:TAWAS BAY OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-362-9546
Mailing Address - Street 1:1691 N US 23
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730
Mailing Address - Country:US
Mailing Address - Phone:989-362-9546
Mailing Address - Fax:
Practice Address - Street 1:1691 N US 23
Practice Address - Street 2:SUITE 2
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730
Practice Address - Country:US
Practice Address - Phone:989-362-9546
Practice Address - Fax:989-362-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003153152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C510060OtherBLUE CROSS BLUE SHIELD
MI410046393OtherRAILROAD MEDICARE
MI0M89210001OtherBCBSM MEDICARE ADVANTAGE
MI1291550002OtherDMERC
MI0M89210001OtherBCBSM MEDICARE ADVANTAGE
MIM89210001Medicare PIN
MI1291550002OtherDMERC