Provider Demographics
NPI:1629105788
Name:ADVANCED EYE CARE OF GRAND RAPIDS, PLC
Entity Type:Organization
Organization Name:ADVANCED EYE CARE OF GRAND RAPIDS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLSER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-361-2020
Mailing Address - Street 1:5258 PLAINFIELD AVE NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5258 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE F
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1092
Practice Address - Country:US
Practice Address - Phone:616-361-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4010004245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4834870Medicaid
MI4834870Medicaid
MIV03793Medicare UPIN