Provider Demographics
NPI:1306827837
Name:GAYLORD EYE CARE CENTER INC
Entity Type:Organization
Organization Name:GAYLORD EYE CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-732-6261
Mailing Address - Street 1:829 W MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1998
Mailing Address - Country:US
Mailing Address - Phone:989-732-6261
Mailing Address - Fax:989-732-1276
Practice Address - Street 1:829 W MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1998
Practice Address - Country:US
Practice Address - Phone:989-732-6261
Practice Address - Fax:989-732-1276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003972152W00000X
MI4901002759152W00000X
MI4901003033152W00000X
MI4901004573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F9100OtherBCBS
MI0379130001Medicare NSC
MION46900Medicare PIN