Provider Demographics
NPI:1790953248
Name:LIVINGSTON COUNTY VISION CENTER
Entity Type:Organization
Organization Name:LIVINGSTON COUNTY VISION CENTER
Other - Org Name:EYE CARE ONE OF LIVINGSTON COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-546-9242
Mailing Address - Street 1:2674 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-8544
Mailing Address - Country:US
Mailing Address - Phone:517-546-9242
Mailing Address - Fax:517-546-7840
Practice Address - Street 1:2674 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8544
Practice Address - Country:US
Practice Address - Phone:517-546-9242
Practice Address - Fax:517-546-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004200OtherSTATE LICENSE NUMBER
MI900D710770OtherBLUE CROSS BLUE SHIELD
MI4787760 TYPE 94Medicaid
MI900D710770OtherBLUE CROSS BLUE SHIELD
MI0P04200Medicare PIN
MI4787760 TYPE 94Medicaid