Provider Demographics
NPI:1801291091
Name:TRI CITIES EYE CARE, PLC
Entity type:Organization
Organization Name:TRI CITIES EYE CARE, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ITS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:AUGUSTO
Authorized Official - Last Name:VENTOCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-962-4011
Mailing Address - Street 1:365 CAPITAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-4829
Mailing Address - Country:US
Mailing Address - Phone:269-962-4011
Mailing Address - Fax:
Practice Address - Street 1:365 CAPITAL AVE NE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-4829
Practice Address - Country:US
Practice Address - Phone:269-962-4011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U59827Medicare UPIN