Healthcare Provider Details

I. General information

NPI: 1053902494
Provider Name (Legal Business Name): MI GREAT LAKES EYECARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 DONOVAN PL
GROSSE POINTE MI
48230-1935
US

IV. Provider business mailing address

12 DONOVAN PL
GROSSE POINTE MI
48230-1935
US

V. Phone/Fax

Practice location:
  • Phone: 646-241-0810
  • Fax:
Mailing address:
  • Phone: 646-241-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH R. BOROWIEC
Title or Position: OPTOMETRIST/OWNER
Credential: OD
Phone: 646-241-0810