Healthcare Provider Details

I. General information

NPI: 1821126384
Provider Name (Legal Business Name): NILES VISION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 S SAINT JOSEPH AVE
NILES MI
49120-2846
US

IV. Provider business mailing address

9 S SAINT JOSEPH AVE
NILES MI
49120-2846
US

V. Phone/Fax

Practice location:
  • Phone: 269-683-4040
  • Fax: 269-683-7565
Mailing address:
  • Phone: 269-683-4040
  • Fax: 269-683-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY JOEL BECRAFT
Title or Position: MANAGING PARTNER
Credential: OPTOMETRIST
Phone: 269-683-4040