Healthcare Provider Details

I. General information

NPI: 1295807626
Provider Name (Legal Business Name): ADRIAN EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 RIVERSIDE AVE
ADRIAN MI
49221-1543
US

IV. Provider business mailing address

580 RIVERSIDE AVE
ADRIAN MI
49221-1543
US

V. Phone/Fax

Practice location:
  • Phone: 517-265-6055
  • Fax: 517-265-6115
Mailing address:
  • Phone: 517-265-6055
  • Fax: 517-265-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4901004286
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4901002974
License Number StateMI

VIII. Authorized Official

Name: PENNY JACKSON
Title or Position: CREDENTIALING
Credential:
Phone: 517-202-1618