Provider Demographics
NPI:1154954741
Name:P-COR, LLC
Entity type:Organization
Organization Name:P-COR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/PRIVILEGING
Authorized Official - Prefix:
Authorized Official - First Name:SHAKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-577-3659
Mailing Address - Street 1:735 JOHN R RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5859
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:
Practice Address - Street 1:29350 SOUTHFIELD RD STE 150
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2011
Practice Address - Country:US
Practice Address - Phone:248-647-9790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720033343Medicaid