Provider Demographics
NPI:1972545697
Name:LO OPTICAL, LLC
Entity type:Organization
Organization Name:LO OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-337-1899
Mailing Address - Street 1:1005 CHARLEVOIX DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8186
Mailing Address - Country:US
Mailing Address - Phone:517-337-1668
Mailing Address - Fax:517-622-1205
Practice Address - Street 1:2790 W GRAND RIVER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8424
Practice Address - Country:US
Practice Address - Phone:517-548-3382
Practice Address - Fax:517-545-2543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5208750005Medicare NSC