Healthcare Provider Details

I. General information

NPI: 1861554636
Provider Name (Legal Business Name): TRAVERSE CITY EYE CONSULTANTS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S CORAL ST
KALKASKA MI
49646-2500
US

IV. Provider business mailing address

5199 N ROYAL DR
TRAVERSE CITY MI
49684-9201
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-8101
  • Fax: 231-935-0955
Mailing address:
  • Phone: 231-935-8101
  • Fax: 231-935-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH B GUM
Title or Position: DOCTOR
Credential: M.D.
Phone: 231-935-8101