Provider Demographics
NPI:1043345986
Name:EYE CARE PROVIDERS OF MICHIGAN PC
Entity Type:Organization
Organization Name:EYE CARE PROVIDERS OF MICHIGAN PC
Other - Org Name:EYE CARE CENTER OF PORT HURON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:CZAJKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-296-7250
Mailing Address - Street 1:PO BOX 26010
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-6010
Mailing Address - Country:US
Mailing Address - Phone:586-296-7250
Mailing Address - Fax:586-296-0276
Practice Address - Street 1:1000 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3733
Practice Address - Country:US
Practice Address - Phone:810-982-3200
Practice Address - Fax:810-982-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P41880Medicare ID - Type Unspecified