Provider Demographics
NPI:1972808921
Name:SHORELINE OPTICAL, LLC
Entity type:Organization
Organization Name:SHORELINE OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-588-6593
Mailing Address - Street 1:1266 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1847
Mailing Address - Country:US
Mailing Address - Phone:616-846-2280
Mailing Address - Fax:616-844-5696
Practice Address - Street 1:625 E SAVIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1956
Practice Address - Country:US
Practice Address - Phone:231-739-9009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty