Provider Demographics
NPI:1356429757
Name:THORP KALACZINSKI, LILLIAN (OD)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:THORP KALACZINSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7421 TREELINE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7465
Mailing Address - Country:US
Mailing Address - Phone:616-970-4630
Mailing Address - Fax:
Practice Address - Street 1:1124 S STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2256
Practice Address - Country:US
Practice Address - Phone:231-591-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4758580Medicaid
U76829Medicare UPIN