Provider Demographics
NPI:1023287836
Name:ROBERT D & CINDY L DOUGLAS
Entity type:Organization
Organization Name:ROBERT D & CINDY L DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-853-6459
Mailing Address - Street 1:12412 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9783
Mailing Address - Country:US
Mailing Address - Phone:231-853-6459
Mailing Address - Fax:231-853-6459
Practice Address - Street 1:12412 STAFFORD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451-0307
Practice Address - Country:US
Practice Address - Phone:231-853-6459
Practice Address - Fax:231-853-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI56038OtherDAVIS VISION
MI900F176110OtherBLUE CROSS BLUESHIELD
MIOP0965OtherEYE MED
MI0797110001Medicare UPIN
0797110001Medicare NSC