Provider Demographics
NPI:1780810598
Name:CANADIAN LAKES EYECARE, P.L.L.C.
Entity type:Organization
Organization Name:CANADIAN LAKES EYECARE, P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-972-3937
Mailing Address - Street 1:10085 BUCHANAN RD
Mailing Address - Street 2:
Mailing Address - City:CANADIAN LAKES
Mailing Address - State:MI
Mailing Address - Zip Code:49346-9762
Mailing Address - Country:US
Mailing Address - Phone:231-972-3937
Mailing Address - Fax:231-972-1212
Practice Address - Street 1:10085 BUCHANAN RD
Practice Address - Street 2:
Practice Address - City:CANADIAN LAKES
Practice Address - State:MI
Practice Address - Zip Code:49346-9762
Practice Address - Country:US
Practice Address - Phone:231-972-3937
Practice Address - Fax:231-972-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty