Provider Demographics
NPI:1568642957
Name:PRIMARY VISION CENTER
Entity Type:Organization
Organization Name:PRIMARY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCNIVEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-648-4242
Mailing Address - Street 1:33 W SANILAC RD
Mailing Address - Street 2:PO BOX 112
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-1036
Mailing Address - Country:US
Mailing Address - Phone:810-648-4242
Mailing Address - Fax:810-648-4248
Practice Address - Street 1:33 W SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1036
Practice Address - Country:US
Practice Address - Phone:810-648-4242
Practice Address - Fax:810-648-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900G665050OtherBCBS OF MI
MI0148520001Medicare NSC