Organization
GRAHAM'S OPTIQUE BOUTIQUE INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOSEPH L DEROSE OPTICAN (OPTICAN)
(313) 562-0001
Entity
Organization
Contact information
Practice address
20100 OUTER DR, DEARBORN, MI 48124-2647
(313) 562-0001
(313) 562-4840
Mailing address
20100 OUTER DRIVE, DEARBORN, MI 48124-2920
(313) 562-0001
(313) 562-4840
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
54OH20415
BLUE CROSS BLUE SHIELD OF MICHIGAN
MI
Enumeration date
02/10/2006
Last updated
10/09/2014
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