Provider Demographics
NPI:1265653224
Name:CEDAR RUN EYE CENTER
Entity Type:Organization
Organization Name:CEDAR RUN EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCHOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-929-3888
Mailing Address - Street 1:3830 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8153
Mailing Address - Country:US
Mailing Address - Phone:231-929-3888
Mailing Address - Fax:231-929-4365
Practice Address - Street 1:3830 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8153
Practice Address - Country:US
Practice Address - Phone:231-929-3888
Practice Address - Fax:231-929-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B86347OtherBCBS
MI3166478Medicaid
MI3166469Medicaid
MI4977003Medicaid
MI4976991Medicaid
MI3166469Medicaid