Healthcare Provider Details

I. General information

NPI: 1407044688
Provider Name (Legal Business Name): ERIC J. SIESEL, O.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 S. M-129
SAULT SAINTE MARIE MI
49783
US

IV. Provider business mailing address

3265 S. M-129
SAULT SAINTE MARIE MI
49783
US

V. Phone/Fax

Practice location:
  • Phone: 906-635-9347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003938
License Number StateMI

VIII. Authorized Official

Name: ERIC SIESEL
Title or Position: PRESIDENT
Credential:
Phone: 906-635-9347