Provider Demographics
NPI:1821126384
Name:NILES VISION CLINIC
Entity Type:Organization
Organization Name:NILES VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:BECRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST
Authorized Official - Phone:269-683-4040
Mailing Address - Street 1:9 S SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2846
Mailing Address - Country:US
Mailing Address - Phone:269-683-4040
Mailing Address - Fax:269-683-7565
Practice Address - Street 1:9 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2846
Practice Address - Country:US
Practice Address - Phone:269-683-4040
Practice Address - Fax:269-683-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0758440001Medicare NSC
ON24860Medicare ID - Type Unspecified