Provider Demographics
NPI:1952092801
Name:THANE, ETTA MARIE (ABOC)
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:MARIE
Last Name:THANE
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4657 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1010
Mailing Address - Country:US
Mailing Address - Phone:989-670-5003
Mailing Address - Fax:
Practice Address - Street 1:1121 E CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1216
Practice Address - Country:US
Practice Address - Phone:989-672-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI157033156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician