Provider Demographics
NPI:1518048214
Name:GRUIZENGA, LANA (OD)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:GRUIZENGA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:
Other - Last Name:HULSEBUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:133 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1429
Mailing Address - Country:US
Mailing Address - Phone:269-657-7288
Mailing Address - Fax:269-655-9063
Practice Address - Street 1:133 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1429
Practice Address - Country:US
Practice Address - Phone:269-657-7288
Practice Address - Fax:269-655-9063
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU32640Medicare UPIN