Provider Demographics
NPI:1497173322
Name:DIETRICH PC
Entity Type:Organization
Organization Name:DIETRICH PC
Other - Org Name:HARRISVILLE EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WESTERGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-724-7440
Mailing Address - Street 1:300 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-9693
Mailing Address - Country:US
Mailing Address - Phone:989-724-7440
Mailing Address - Fax:989-724-7531
Practice Address - Street 1:300 N STATE ST
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9693
Practice Address - Country:US
Practice Address - Phone:989-724-7440
Practice Address - Fax:989-724-7531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004764152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty