1780888081 NPI number — FOWLE EYECARE ASSOCIATES PLC

Table of content: (NPI 1780888081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780888081 NPI number — FOWLE EYECARE ASSOCIATES PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOWLE EYECARE ASSOCIATES 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:
1780888081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 MARCELL DR NE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49341-1362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-866-0140
Provider Business Mailing Address Fax Number:
616-866-8694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 MARCELL DR NE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49341-1362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-866-0140
Provider Business Practice Location Address Fax Number:
616-866-8694
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOLWE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
616-866-0140

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901002906 , 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: 5106316 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900D166020 . This is a "BCBSM & BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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