Basic Information
| Provider Information | |||||||||
| NPI: | 1770592602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANSEN VISION CENTER PLC | ||||||||
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| OtherOrganizationName: | HANSEN VISION CENTER PLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S FRANKLIN | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488381905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167547143 | ||||||||
| FaxNumber: | 6167542778 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 S FRANKLIN | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488381905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167547143 | ||||||||
| FaxNumber: | 6167542778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 6167547143 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002646 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 900E97604 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 01256 | 01 | MI | PRIORITY HEALTH | OTHER |