Provider Demographics
NPI:1417137084
Name:FAMILY & PEDIATRIC EYE CARE PLC
Entity Type:Organization
Organization Name:FAMILY & PEDIATRIC EYE CARE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STORE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:FONGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-459-0641
Mailing Address - Street 1:144 MONROE CTR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2802
Mailing Address - Country:US
Mailing Address - Phone:616-459-0641
Mailing Address - Fax:616-459-0621
Practice Address - Street 1:144 MONROE CENTER
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2802
Practice Address - Country:US
Practice Address - Phone:616-459-0641
Practice Address - Fax:616-459-0621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002505152WC0802X
MI4901004219152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D114840OtherBCBS PIN #
MIU92856OtherUPIN
MI0P19680OtherMEDICARE GROUP NUMBER
MIT33048OtherUPIN
MI4599036Medicaid
MI900D114850OtherBCBS PIN #
MI5041964Medicaid
MI0P19680OtherMEDICARE GROUP NUMBER
MI4599036Medicaid
MI5474550001Medicare NSC