Provider Demographics
NPI:1497812150
Name:THREE RIVERS EYECARE PC
Entity Type:Organization
Organization Name:THREE RIVERS EYECARE PC
Other - Org Name:SUSSEX VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSSEX
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-694-9462
Mailing Address - Street 1:56847 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49036
Mailing Address - Country:US
Mailing Address - Phone:269-273-5825
Mailing Address - Fax:269-279-6010
Practice Address - Street 1:123 S FAIR STREET
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MI
Practice Address - Zip Code:49078
Practice Address - Country:US
Practice Address - Phone:269-694-9462
Practice Address - Fax:269-694-5826
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THREE RIVERS EYECARE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945191120Medicaid
MI900G510070OtherBCBS
MI944696853Medicaid
MI1251300002Medicare NSC
MI945191120Medicaid