1578690707 NPI number — EYE CARE ASSOCIATES OF OWOSSO, P.C.

Table of content: (NPI 1578690707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578690707 NPI number — EYE CARE ASSOCIATES OF OWOSSO, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE ASSOCIATES OF OWOSSO, P.C.
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:
1578690707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 S ELM ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
OWOSSO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48867-2636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-723-1101
Provider Business Mailing Address Fax Number:
989-723-1665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 S ELM ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
OWOSSO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48867-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-723-1101
Provider Business Practice Location Address Fax Number:
989-723-1665
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAKI
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-723-1101

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901 , 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: 1699252 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1699261 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4723404 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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