Provider Demographics
NPI:1063450278
Name:THREE RIVERS EYECARE PC
Entity Type:Organization
Organization Name:THREE RIVERS EYECARE PC
Other - Org Name:SUSSEX VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSSEX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-278-6303
Mailing Address - Street 1:56847 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093
Mailing Address - Country:US
Mailing Address - Phone:269-273-5825
Mailing Address - Fax:269-279-6010
Practice Address - Street 1:56847 N MAIN ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093
Practice Address - Country:US
Practice Address - Phone:269-273-5825
Practice Address - Fax:269-279-6010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS EYECARE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944696844Medicaid
MI900G510070OtherBCBS
MI945191148Medicaid
MI945215713Medicaid
MI943465664Medicaid
MI944553494Medicaid
MI944696844Medicaid
MI943465664Medicaid
MI945215713Medicaid