Healthcare Provider Details

I. General information

NPI: 1518029909
Provider Name (Legal Business Name): CEDAR RUN EYE CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 W FRONT ST
TRAVERSE CITY MI
49684-8153
US

IV. Provider business mailing address

3830 W FRONT ST
TRAVERSE CITY MI
49684-8153
US

V. Phone/Fax

Practice location:
  • Phone: 231-929-3888
  • Fax: 231-929-4365
Mailing address:
  • Phone: 231-929-3888
  • Fax: 231-929-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003094
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003086
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004107
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301048021
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4301048021
License Number StateMI

VIII. Authorized Official

Name: DR. TIMOTHY B. HANLEY
Title or Position: OWNER
Credential: M.D.
Phone: 231-929-3888