Provider Demographics
NPI:1447511456
Name:VERGOS VISION SERVICE INC
Entity type:Organization
Organization Name:VERGOS VISION SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-244-3434
Mailing Address - Street 1:3385 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1457
Mailing Address - Country:US
Mailing Address - Phone:810-244-3434
Mailing Address - Fax:810-715-0301
Practice Address - Street 1:3385 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1457
Practice Address - Country:US
Practice Address - Phone:810-244-3434
Practice Address - Fax:810-715-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM11270Medicare UPIN