Provider Demographics
NPI:1447326244
Name:FRASER OPTICAL CLINIC, INC.
Entity type:Organization
Organization Name:FRASER OPTICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:STEFANI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-293-8888
Mailing Address - Street 1:32925 GROESBECK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026
Mailing Address - Country:US
Mailing Address - Phone:586-293-8888
Mailing Address - Fax:586-296-0726
Practice Address - Street 1:32925 GROESBECK HIGHWAY
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026
Practice Address - Country:US
Practice Address - Phone:586-293-8888
Practice Address - Fax:586-296-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
900E06513OtherBCBS
110955OtherEYEMED
MI3404800Medicaid
110955OtherEYEMED
MI3404800Medicaid