Healthcare Provider Details

I. General information

NPI: 1871852939
Provider Name (Legal Business Name): SOUTHWEST VISION CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69001 M 62 SUITE E
EDWARDSBURG MI
49112-9131
US

IV. Provider business mailing address

69001 M 62 SUITE E
EDWARDSBURG MI
49112-9131
US

V. Phone/Fax

Practice location:
  • Phone: 989-289-2669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004625
License Number StateMI

VIII. Authorized Official

Name: JENNIFER LAMBART
Title or Position: PRESIDENT
Credential:
Phone: 989-289-2669