Provider Demographics
NPI:1508248071
Name:SIGNATURE EYE CARE INC
Entity Type:Organization
Organization Name:SIGNATURE EYE CARE INC
Other - Org Name:SIGNATURE EYE CARE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-228-4790
Mailing Address - Street 1:6290 JUPITER AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-8885
Mailing Address - Country:US
Mailing Address - Phone:616-228-4790
Mailing Address - Fax:
Practice Address - Street 1:6290 JUPITER AVE NE STE A
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-8885
Practice Address - Country:US
Practice Address - Phone:616-228-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty