Provider Demographics
NPI:1710128111
Name:WEST COAST EYECARE PLLC
Entity Type:Organization
Organization Name:WEST COAST EYECARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST: ITS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:MULDER
Authorized Official - Last Name:DEJONGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-395-2020
Mailing Address - Street 1:456 E 16TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3788
Mailing Address - Country:US
Mailing Address - Phone:616-395-2020
Mailing Address - Fax:616-396-8628
Practice Address - Street 1:456 E 16TH ST STE 1
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3788
Practice Address - Country:US
Practice Address - Phone:616-395-2020
Practice Address - Fax:616-396-8628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6451360001Medicare NSC
MIMI1501Medicare PIN