Provider Demographics
NPI:1912958919
Name:ADVANCED FAMILY EYE CARE, PC
Entity Type:Organization
Organization Name:ADVANCED FAMILY EYE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCIESZKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-429-6781
Mailing Address - Street 1:2810 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3338
Mailing Address - Country:US
Mailing Address - Phone:269-429-6781
Mailing Address - Fax:269-429-5006
Practice Address - Street 1:2810 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3338
Practice Address - Country:US
Practice Address - Phone:269-429-6781
Practice Address - Fax:269-429-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-14
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4627201Medicaid
MIU89463Medicare UPIN
MI0P08100Medicare ID - Type UnspecifiedGROUP PROVIDER #
MI0P08100Medicare PIN