Provider Demographics
NPI:1083744379
Name:SOUTH HAVEN EYECARE ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH HAVEN EYECARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BACAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-637-1442
Mailing Address - Street 1:1088 BAILEY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6723
Mailing Address - Country:US
Mailing Address - Phone:269-637-1442
Mailing Address - Fax:269-637-3801
Practice Address - Street 1:1088 S BAILEY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6723
Practice Address - Country:US
Practice Address - Phone:269-637-1442
Practice Address - Fax:269-637-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI490100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H07612OtherBLUE CROSS BLUE SHIELD
MI0H07612OtherBLUE CROSS BLUE SHIELD
MI0240320001Medicare NSC