Provider Demographics
NPI:1417179862
Name:ABP EYESITE PC
Entity Type:Organization
Organization Name:ABP EYESITE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS REC.
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-773-2020
Mailing Address - Street 1:1230 E.BROOMFIELD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MT.PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-773-2020
Mailing Address - Fax:989-772-7757
Practice Address - Street 1:1230 E.BROOMFIELD
Practice Address - Street 2:SUITE 6
Practice Address - City:MT.PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-2020
Practice Address - Fax:989-772-7757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C710170OtherBLUECROSS BLUESHIELD
MI0N43230Medicare UPIN
MI4379490001Medicare NSC