Provider Demographics
NPI:1235311200
Name:LAPEER COUNTY EYE ASSOCIATES INC
Entity Type:Organization
Organization Name:LAPEER COUNTY EYE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-664-3937
Mailing Address - Street 1:333 W NEPESSING ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2105
Mailing Address - Country:US
Mailing Address - Phone:810-664-3937
Mailing Address - Fax:
Practice Address - Street 1:333 W NEPESSING ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2105
Practice Address - Country:US
Practice Address - Phone:810-664-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N64360Medicare PIN
MI4922670001Medicare NSC