1255344305 NPI number — JARDON EYE PROSTHETICS, INC.

Table of content: DR. RICHARD MICHAEL HOFACKER DPM (NPI 1356319917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255344305 NPI number — JARDON EYE PROSTHETICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JARDON EYE PROSTHETICS, INC.
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:
1255344305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15920 W 12 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-3047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-424-8560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15920 W 12 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-3047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-424-8560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
LEE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-424-8560

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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: 2829576 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8333001 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 9002104 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F30983 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: ANO369 . This is a "SELECT CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 500490 . This is a "MERCY HEALTH PLANS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 29933 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 49394 . This is a "OMNICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 82-09450 . This is a "PHP LANSING" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 82-29048 . This is a "PHP-JACKSON" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OP630172 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P500490 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000006595 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 120109-0001 . This is a "WELLNESS PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1267 . This is a "NORTHWOODS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5131 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 80276A . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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