Healthcare Provider Details

I. General information

NPI: 1629019914
Provider Name (Legal Business Name): SCOTT RICHARD ECENBARGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 BYRON CENTER AVE SW SUITE V
WYOMING MI
49519-9621
US

IV. Provider business mailing address

5751 BYRON CENTER AVE SW SUITE V
WYOMING MI
49519-9621
US

V. Phone/Fax

Practice location:
  • Phone: 616-532-2020
  • Fax: 616-532-2022
Mailing address:
  • Phone: 616-532-2020
  • Fax: 616-532-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004003
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: