Heritage Optical Center Inc
Organization Active NPI Optometrist · Detroit, MI
NPI 1285728964 · NPPES record last updated Dec 20, 2023
Key facts
- NPI
- 1285728964
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- 4601003146 (MI)
- Legal business name
- HERITAGE OPTICAL CENTER INC
- Practice address
- 19010 Livernois Ave
Detroit, MI 48221-2259 - Phone
- (313) 863-9581
- Fax
- (313) 863-7710
- NPI assigned
- Oct 3, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. George P Barnes Jr.
- Title
- Owner Ceo
- Phone
- (313) 863-9585
Corporate family (same tax ID) 3
Practitioners 18
-
Jodi Ann Bergstrom, O.D.
-
Puja H. Desai, O.D.
-
Terri-Ann Bailey Echague, O.D.
-
Rachel Lyn Hawran, O.D.
-
Fatima Karim, O.D.
-
Al'Tiana Manning, OD
-
Laura J Bahorski, O.D.
-
Dawn Caldwell, OD
-
Robert Emmett Deck III, O.D.
-
Jennifer Cooper Dudovitz, O.D.
-
Wassim H Fakih, OD
-
Iqjyot Kaur Gill, O.D.
-
Lanny Green, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071024000612 | MI | Part B Supplier - Clinic/Group Practice | 1052408986 |
Receives reassigned benefits from 18 practitioners Practice locations: Detroit, MI |
National Provider Directory
- Tax ID family
- Heritage Optical Center Inc
Locations
19010 Livernois Ave
Detroit, MI 48221
Phone (313) 863-9581
2678 E Jefferson Ave
Detroit, MI 48207
Phone (313) 259-6006
87 Monroe St
Detroit, MI 48226
Phone (313) 863-9585
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | 4601003146 | MI | Yes |
Addresses
Primary practice location
19010 Livernois Ave
Detroit, MI 48221-2259
Mailing address
19010 Livernois Ave
Detroit, MI 48221-2259
Phone (313) 863-9581
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2831091 | Medicaid | MI | |
| 4971556 | Medicaid | MI | |
| 5102658 | Medicaid | MI |
Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 20, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.