Healthcare Provider Details

I. General information

NPI: 1003997651
Provider Name (Legal Business Name): JEFFREY B. BYLAND, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/06/2020
Certification Date: 12/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S DIVISION AVE
FREMONT MI
49412-1602
US

IV. Provider business mailing address

103 S DIVISION AVE
FREMONT MI
49412-1602
US

V. Phone/Fax

Practice location:
  • Phone: 231-924-4110
  • Fax: 231-924-5007
Mailing address:
  • Phone: 231-924-4110
  • Fax: 231-924-5007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4901002849
License Number StateMI

VIII. Authorized Official

Name: DR. LARA A EENIGENBURG
Title or Position: PRESIDENT
Credential: OD
Phone: 231-924-4110