Provider Demographics
NPI:1477680015
Name:PAUL W LANCZKI PC
Entity Type:Organization
Organization Name:PAUL W LANCZKI PC
Other - Org Name:ADRIAN EYECARE AND OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-265-6055
Mailing Address - Street 1:1136 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-8208
Mailing Address - Country:US
Mailing Address - Phone:517-265-6055
Mailing Address - Fax:517-265-6115
Practice Address - Street 1:1136 COUNTRY CLUB RD
Practice Address - Street 2:SUITE C
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-8208
Practice Address - Country:US
Practice Address - Phone:517-265-6055
Practice Address - Fax:517-265-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002974152W00000X
MI4901004286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4639178-86OtherMEDICAID DISPENSING
MI5276880001Medicare NSC