Organization
FOR YOUR EYES ONLY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANA SULLIVAN (OWNER)
(248) 557-3212
Entity
Organization
Contact information
Practice address
26059 SOUTHFIELD RD, LATHRUP VILLAGE, MI 48076-4526
(248) 557-3212
Mailing address
26059 SOUTHFIELD RD, LATHRUP VILLAGE, MI 48076-4526
(248) 557-3212
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
900F377150
BCBS OF MI
MI
Enumeration date
02/19/2007
Last updated
02/25/2014
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