Healthcare Provider Details

I. General information

NPI: 1508927286
Provider Name (Legal Business Name): CASCADE OPHTHALMOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8625
US

IV. Provider business mailing address

791 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8625
US

V. Phone/Fax

Practice location:
  • Phone: 616-575-8200
  • Fax: 616-954-9622
Mailing address:
  • Phone: 616-575-8200
  • Fax: 616-954-9622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4301070226
License Number StateMI

VIII. Authorized Official

Name: ELIZABETH H HENRY
Title or Position: OWNER
Credential: MD
Phone: 616-575-8200