1174974356 NPI number — OCULOPLASTIC ASSOCIATES OF WEST MICHIGAN, PLC

Table of content: (NPI 1174974356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174974356 NPI number — OCULOPLASTIC ASSOCIATES OF WEST MICHIGAN, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCULOPLASTIC ASSOCIATES OF WEST MICHIGAN, PLC
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:
Provider Other Organization Name Type Code:
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:
1174974356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4070 LAKE DR SE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-8294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-888-2948
Provider Business Mailing Address Fax Number:
616-888-2949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4070 LAKE DR SE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-8294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-888-2948
Provider Business Practice Location Address Fax Number:
616-888-2949
Provider Enumeration Date:
06/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER, PHYSICIAN
Authorized Official Telephone Number:
616-888-2948

Provider Taxonomy Codes

  • Taxonomy code: 207WX0200X , with the licence number:  4301092933 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1164686812 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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