Healthcare Provider Details

I. General information

NPI: 1124338736
Provider Name (Legal Business Name): SWAN OPTOMETRY SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N MAIN ST
ROCKFORD MI
49341-1281
US

IV. Provider business mailing address

25 N MAIN ST
ROCKFORD MI
49341-1281
US

V. Phone/Fax

Practice location:
  • Phone: 616-866-3077
  • Fax: 616-866-4408
Mailing address:
  • Phone: 616-866-3077
  • Fax: 616-866-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003186
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901003186
License Number StateMI

VIII. Authorized Official

Name: MARK SWAN
Title or Position: OWNER
Credential: OD, MED
Phone: 616-866-3077