Provider Demographics
NPI:1902194970
Name:PRIMARY EYE AND VISION CARE, LLC
Entity Type:Organization
Organization Name:PRIMARY EYE AND VISION CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:863-368-0502
Mailing Address - Street 1:1191 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-1005
Mailing Address - Country:US
Mailing Address - Phone:517-546-4655
Mailing Address - Fax:517-546-0899
Practice Address - Street 1:1191 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1005
Practice Address - Country:US
Practice Address - Phone:517-546-4655
Practice Address - Fax:517-546-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902194970OtherBLUE CROSS BLUE SHIELD
MIMI4786OtherMEDICARE
MI6639430001Medicare NSC
MIMI4786Medicare PIN