Provider Demographics
NPI:1164562393
Name:CYNTHIA M KACZMAREK
Entity Type:Organization
Organization Name:CYNTHIA M KACZMAREK
Other - Org Name:EYECARE CONNECTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KACZMAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-887-4175
Mailing Address - Street 1:2942 E HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48356-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2942 E HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48356-2810
Practice Address - Country:US
Practice Address - Phone:248-887-4175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002311152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6736Medicare PIN