Provider Demographics
NPI:1992811632
Name:C & C OPTICAL SHOP INC.
Entity type:Organization
Organization Name:C & C OPTICAL SHOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-924-1988
Mailing Address - Street 1:1007 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1420
Mailing Address - Country:US
Mailing Address - Phone:231-924-1988
Mailing Address - Fax:231-924-1622
Practice Address - Street 1:1007 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1420
Practice Address - Country:US
Practice Address - Phone:231-924-1988
Practice Address - Fax:231-924-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1262670001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3455345Medicaid
MIU78263Medicare UPIN
MI3455345Medicaid
MI1262670001Medicare NSC