Provider Demographics
NPI:1699320028
Name:EYEGLASSES ONLINE DIRECT
Entity type:Organization
Organization Name:EYEGLASSES ONLINE DIRECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED OPTICIAN
Authorized Official - Phone:586-915-7465
Mailing Address - Street 1:41975 BROOKVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5227
Mailing Address - Country:US
Mailing Address - Phone:586-915-7465
Mailing Address - Fax:
Practice Address - Street 1:41975 BROOKVIEW LN
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5227
Practice Address - Country:US
Practice Address - Phone:586-915-7465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier