Basic Information
| Provider Information | |||||||||
| NPI: | 1114058369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT LAKES EYE CARE, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREAT LAKES EYE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2848 NILES RD | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490853352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694283300 | ||||||||
| FaxNumber: | 2694285005 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 PHOENIX ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696373101 | ||||||||
| FaxNumber: | 2696374000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKS | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 2694283300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREAT LAKES EYE CARE, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | B.S. | ||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.