Provider Demographics
NPI:1508927286
Name:CASCADE OPHTHALMOLOGY PC
Entity Type:Organization
Organization Name:CASCADE OPHTHALMOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-575-8200
Mailing Address - Street 1:791 KENMOOR AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8625
Mailing Address - Country:US
Mailing Address - Phone:616-575-8200
Mailing Address - Fax:616-954-9622
Practice Address - Street 1:791 KENMOOR AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8625
Practice Address - Country:US
Practice Address - Phone:616-575-8200
Practice Address - Fax:616-954-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070226332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5012170001Medicare NSC