Healthcare Provider Details

I. General information

NPI: 1659412302
Provider Name (Legal Business Name): ERIC CONNICK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2279 S AIRPORT RD W
TRAVERSE CITY MI
49684-4713
US

IV. Provider business mailing address

105 W EXCHANGE ST
SPRING LAKE MI
49456-2024
US

V. Phone/Fax

Practice location:
  • Phone: 231-932-1520
  • Fax: 231-932-1552
Mailing address:
  • Phone: 616-846-0620
  • Fax: 616-844-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: