Provider Demographics
NPI:1780888081
Name:FOWLE EYECARE ASSOCIATES PLC
Entity type:Organization
Organization Name:FOWLE EYECARE ASSOCIATES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOLWE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-866-0140
Mailing Address - Street 1:120 MARCELL DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1362
Mailing Address - Country:US
Mailing Address - Phone:616-866-0140
Mailing Address - Fax:616-866-8694
Practice Address - Street 1:120 MARCELL DR NE
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1362
Practice Address - Country:US
Practice Address - Phone:616-866-0140
Practice Address - Fax:616-866-8694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5106316Medicaid
MI900D166020OtherBCBSM & BLUE CARE NETWORK
MI900D166020OtherBCBSM & BLUE CARE NETWORK
MIT33057Medicare UPIN
0N42300Medicare PIN