Provider Demographics
NPI:1033199153
Name:EYE CARE ONE, INC.
Entity Type:Organization
Organization Name:EYE CARE ONE, INC.
Other - Org Name:EYE CARE ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-846-0620
Mailing Address - Street 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:314 W SAVIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1607
Practice Address - Country:US
Practice Address - Phone:616-844-7000
Practice Address - Fax:616-844-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI(94)4616567Medicaid
MI4901002359OtherJEROME MCDOWELL LICENSE
MI=========OtherTAX ID
MI900G065420OtherBCBS OF MICHIGAN
MIP00338094Medicare ID - Type UnspecifiedRAILROAD PROVIDER ID
MI=========OtherTAX ID
MIU60722Medicare UPIN
MIN88020007Medicare ID - Type UnspecifiedMEDICARE DOCTOR NUMBER
MI(94)4616567Medicaid
MI4080110001Medicare NSC