Provider Demographics
NPI:1619315926
Name:CHARLEVOIX EYE CENTER, P.C.
Entity Type:Organization
Organization Name:CHARLEVOIX EYE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANWAGNEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-916-6168
Mailing Address - Street 1:1008 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1008 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1602
Practice Address - Country:US
Practice Address - Phone:231-547-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-08
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty