Healthcare Provider Details

I. General information

NPI: 1326318734
Provider Name (Legal Business Name): FRUITPORT FAMILY EYE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 N 3RD AVE STE I
FRUITPORT MI
49415-9785
US

IV. Provider business mailing address

388 N 3RD AVE STE I
FRUITPORT MI
49415-9785
US

V. Phone/Fax

Practice location:
  • Phone: 231-865-9990
  • Fax: 231-865-9991
Mailing address:
  • Phone: 231-865-9990
  • Fax: 231-865-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003947
License Number StateMI

VIII. Authorized Official

Name: DR. DEBORAH LYNN OSBORNE
Title or Position: SINGLE OWNER
Credential: O.D.
Phone: 231-865-9990