Provider Demographics
NPI:1477617579
Name:ELDER EYE CARE GROUP PLC
Entity Type:Organization
Organization Name:ELDER EYE CARE GROUP PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:VENTOCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-502-0069
Mailing Address - Street 1:15666 RIVER SIDE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9243
Mailing Address - Country:US
Mailing Address - Phone:616-502-0069
Mailing Address - Fax:
Practice Address - Street 1:15666 RIVER SIDE DR
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9243
Practice Address - Country:US
Practice Address - Phone:616-502-0069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00329735OtherRR MEDICARE NUMBER
MI90G011590OtherBLUE CROSS BLUE SHIELD
MI900029831OtherPRIORITY HEALTH
MI4820570Medicaid
MI0P24730Medicare ID - Type UnspecifiedMEDICARE