Provider Demographics
NPI:1629119805
Name:TRAVEL EYECARE PC
Entity Type:Organization
Organization Name:TRAVEL EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-891-9282
Mailing Address - Street 1:7978 GOLF MEADOWS DR SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8069
Mailing Address - Country:US
Mailing Address - Phone:616-891-9282
Mailing Address - Fax:
Practice Address - Street 1:7978 GOLF MEADOWS DR SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8069
Practice Address - Country:US
Practice Address - Phone:616-891-9282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4417090Medicaid
MI4417090Medicaid