Provider Demographics
NPI:1235487406
Name:GREAT LAKES INDEPENDENT EYECARE NETWORK LLC
Entity Type:Organization
Organization Name:GREAT LAKES INDEPENDENT EYECARE NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-228-4401
Mailing Address - Street 1:2425 LUDINGTON ST
Mailing Address - Street 2:PMB 175
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1328
Mailing Address - Country:US
Mailing Address - Phone:906-466-9070
Mailing Address - Fax:906-466-9071
Practice Address - Street 1:W4790 SKI VIEW RD
Practice Address - Street 2:
Practice Address - City:VULCAN
Practice Address - State:MI
Practice Address - Zip Code:49892-8720
Practice Address - Country:US
Practice Address - Phone:877-488-8900
Practice Address - Fax:844-810-8643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-20
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization