Provider Demographics
NPI:1902998099
Name:GRAND BLANC EYES PLLC
Entity Type:Organization
Organization Name:GRAND BLANC EYES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:AGNONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-694-3937
Mailing Address - Street 1:11225 S SAGINAW ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1285
Mailing Address - Country:US
Mailing Address - Phone:810-694-3937
Mailing Address - Fax:810-694-9876
Practice Address - Street 1:11225 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1285
Practice Address - Country:US
Practice Address - Phone:810-694-3937
Practice Address - Fax:810-694-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B511570OtherBLUE CROSS BLUE SHIELD
MI0995464OtherHEALTHPLUS OF MICHIGAN
MI0995464OtherHEALTHPLUS OF MICHIGAN
0N54540Medicare ID - Type Unspecified