Provider Demographics
NPI:1679721120
Name:FRIENDS OF VISION INTERPERSONAL SERVICES
Entity type:Organization
Organization Name:FRIENDS OF VISION INTERPERSONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GWYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:313-258-2086
Mailing Address - Street 1:5390 CAMBOURNE PL
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4101
Mailing Address - Country:US
Mailing Address - Phone:313-258-2086
Mailing Address - Fax:248-757-2098
Practice Address - Street 1:17500 NORTHLAND PARK CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4324
Practice Address - Country:US
Practice Address - Phone:248-757-2098
Practice Address - Fax:248-757-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization