Provider Demographics
NPI:1487799599
Name:PROFESSIONAL CONTACT LENS CLINIC INC.
Entity type:Organization
Organization Name:PROFESSIONAL CONTACT LENS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:DEMERCURIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-737-3937
Mailing Address - Street 1:30660 W 12 MILE RD
Mailing Address - Street 2:FARMINGTON HILLS
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3808
Mailing Address - Country:US
Mailing Address - Phone:248-737-3937
Mailing Address - Fax:248-737-2816
Practice Address - Street 1:30660 W 12 MILE RD
Practice Address - Street 2:FARMINGTON HILLS
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3808
Practice Address - Country:US
Practice Address - Phone:248-737-3937
Practice Address - Fax:248-737-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4432OtherMEDICARE PTAN