Provider Demographics
NPI:1285728964
Name:HERITAGE OPTICAL CENTER INC
Entity type:Organization
Organization Name:HERITAGE OPTICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-863-9585
Mailing Address - Street 1:19010 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2259
Mailing Address - Country:US
Mailing Address - Phone:313-863-9581
Mailing Address - Fax:313-863-7710
Practice Address - Street 1:19010 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2259
Practice Address - Country:US
Practice Address - Phone:313-863-9581
Practice Address - Fax:313-863-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4601003146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2831091Medicaid
MI4971556Medicaid
MI5102658Medicaid
MIP49080003Medicare PIN
MIP49080002Medicare PIN
MI2831091Medicaid