Healthcare Provider Details

I. General information

NPI: 1831174879
Provider Name (Legal Business Name): CADILLAC EYE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 COBB ST
CADILLAC MI
49601-2577
US

IV. Provider business mailing address

502 COBBS ST
CADILLAC MI
49601-2577
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-1248
  • Fax: 231-775-1156
Mailing address:
  • Phone: 231-775-1248
  • Fax: 231-775-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MICHAEL BRENZ
Title or Position: PRESIDENT
Credential: MD
Phone: 231-775-1248