1225489909 NPI number — SPECIALIZED EYE CARE AND EYE WEAR SERVICES, PLLC

Table of content: (NPI 1225489909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225489909 NPI number — SPECIALIZED EYE CARE AND EYE WEAR SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED EYE CARE AND EYE WEAR SERVICES, PLLC
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:
6
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:
1225489909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7269 SHORE RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALKASKA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49646-8770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 W SOUTH AIRPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-4760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-947-6767
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SOAVE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
480-297-8336

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901004572 , 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)





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