Provider Demographics
NPI:1770862716
Name:REALEYES EYE CARE, LLC
Entity Type:Organization
Organization Name:REALEYES EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPONSELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-674-4738
Mailing Address - Street 1:PO BOX 1380
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-1380
Mailing Address - Country:US
Mailing Address - Phone:734-674-4738
Mailing Address - Fax:
Practice Address - Street 1:47B POLIQUIN DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-1380
Practice Address - Country:US
Practice Address - Phone:734-674-4738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH799G152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1770862716Medicaid
NH0024988Medicare PIN
ME002498801Medicare PIN