Healthcare Provider Details

I. General information

NPI: 1922069806
Provider Name (Legal Business Name): CHILDRENS EYE CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22731 NEWMAN ST STE 245
DEARBORN MI
48124-2023
US

IV. Provider business mailing address

6689 ORCHARD LAKE RD # 297
WEST BLOOMFIELD MI
48322-3404
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-1777
  • Fax: 313-561-8044
Mailing address:
  • Phone: 248-254-8140
  • Fax: 248-254-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN ROARTY
Title or Position: PRESIDENT
Credential: MD
Phone: 313-561-1777