Provider Demographics
NPI:1114058369
Name:GREAT LAKES EYE CARE, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES EYE CARE, P.C.
Other - Org Name:GREAT LAKES EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:269-428-3300
Mailing Address - Street 1:2848 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3352
Mailing Address - Country:US
Mailing Address - Phone:269-428-3300
Mailing Address - Fax:269-428-5005
Practice Address - Street 1:570 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1420
Practice Address - Country:US
Practice Address - Phone:269-637-3101
Practice Address - Fax:269-637-4000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES EYE CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0321930003Medicare NSC