Provider Demographics
NPI:1679754816
Name:MICHIGAN EYECARE INSTITUTE, P.C.
Entity Type:Organization
Organization Name:MICHIGAN EYECARE INSTITUTE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:248-352-2806
Mailing Address - Street 1:29877 TELEGRAPH RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1332
Mailing Address - Country:US
Mailing Address - Phone:248-352-2806
Mailing Address - Fax:
Practice Address - Street 1:29877 TELEGRAPH RD
Practice Address - Street 2:SUITE #100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1332
Practice Address - Country:US
Practice Address - Phone:248-352-2806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004206152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF319240OtherBCBS VISION