Provider Demographics
NPI:1417065616
Name:HCL OF WEST MICHIGAN LLC
Entity Type:Organization
Organization Name:HCL OF WEST MICHIGAN LLC
Other - Org Name:EYE CARE ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS-PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-719-9200
Mailing Address - Street 1:1871 HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1594
Mailing Address - Country:US
Mailing Address - Phone:231-719-9200
Mailing Address - Fax:231-744-6782
Practice Address - Street 1:1871 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1594
Practice Address - Country:US
Practice Address - Phone:231-719-9200
Practice Address - Fax:231-719-6782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F111560OtherBCBS OF MICHIGAN
MIU68516Medicare UPIN
MI5548200002Medicare NSC
MI900F111560OtherBCBS OF MICHIGAN