Provider Demographics
NPI:1679873343
Name:PORTAGE FAMILY VISION CARE, PC
Entity Type:Organization
Organization Name:PORTAGE FAMILY VISION CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-324-4242
Mailing Address - Street 1:6483 S. WESTNEDGE AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3542
Mailing Address - Country:US
Mailing Address - Phone:269-324-4242
Mailing Address - Fax:269-324-6145
Practice Address - Street 1:6483 S. WESTNEDGE AVE.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3542
Practice Address - Country:US
Practice Address - Phone:269-324-4242
Practice Address - Fax:269-324-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004152152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4929042Medicaid
MION61540Medicare PIN
MI4929042Medicaid