Provider Demographics
NPI:1679807176
Name:MODERN EYECARE, P.C.
Entity Type:Organization
Organization Name:MODERN EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-651-3937
Mailing Address - Street 1:2025 25 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-0941
Mailing Address - Country:US
Mailing Address - Phone:248-651-3937
Mailing Address - Fax:248-651-5006
Practice Address - Street 1:2025 25 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-0941
Practice Address - Country:US
Practice Address - Phone:248-651-3937
Practice Address - Fax:248-651-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004068152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578614079OtherNPI FOR INDIVIDUAL
MIU81511Medicare UPIN
MION89140Medicare PIN