Provider Demographics
NPI:1477960813
Name:ROCKFORD FAMILY EYECARE, LLC
Entity type:Organization
Organization Name:ROCKFORD FAMILY EYECARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SEES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-308-4796
Mailing Address - Street 1:4209 N DEARING RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9726
Mailing Address - Country:US
Mailing Address - Phone:202-308-4796
Mailing Address - Fax:
Practice Address - Street 1:2745 10 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9146
Practice Address - Country:US
Practice Address - Phone:202-308-4796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901004807Medicaid
MI4901004807Medicaid
MI1235320680Medicare UPIN
MI4901004807Medicare NSC