Provider Demographics
NPI:1770526436
Name:LAKEVILLE EYE CARE CENTER, INC.
Entity type:Organization
Organization Name:LAKEVILLE EYE CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ENNIS-DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-871-9552
Mailing Address - Street 1:9575 STATE RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9482
Mailing Address - Country:US
Mailing Address - Phone:989-871-9552
Mailing Address - Fax:989-871-9554
Practice Address - Street 1:9575 STATE RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:MI
Practice Address - Zip Code:48746-9482
Practice Address - Country:US
Practice Address - Phone:989-871-9552
Practice Address - Fax:989-871-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944743819Medicaid
MI944743819Medicaid
MIU53521Medicare UPIN