Provider Demographics
NPI:1669470159
Name:BACAK, ALICE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:MARIE
Last Name:BACAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1088 S BAILEY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9728
Mailing Address - Country:US
Mailing Address - Phone:269-637-1442
Mailing Address - Fax:269-637-3801
Practice Address - Street 1:1088 S BAILEY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9728
Practice Address - Country:US
Practice Address - Phone:269-637-1442
Practice Address - Fax:269-637-3801
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1994216Medicaid
MIT96839Medicare UPIN
MI0240320001Medicare NSC
MI0H07612Medicare PIN