1124338736 NPI number — SWAN OPTOMETRY SERVICES, PC

Table of content: (NPI 1124338736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124338736 NPI number — SWAN OPTOMETRY SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWAN OPTOMETRY SERVICES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IN FOCUS EYECARE OF ROCKFORD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124338736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49341-1281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-866-3077
Provider Business Mailing Address Fax Number:
616-866-4408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49341-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-866-3077
Provider Business Practice Location Address Fax Number:
616-866-4408
Provider Enumeration Date:
10/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SWAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
616-866-3077

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003186 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WP0200X , with the licence number: 4901003186 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 900006367 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4401840 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 999998001 . This is a "VSP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: M5003186 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com