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General NPI Number Information
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NPI Number | 1477617579
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Entity Type | Organization
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Legal Business Name | ELDER EYE CARE GROUP PLC
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 09/14/2012
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Provider Practice Location Address
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Address Line | 15666 RIVER SIDE DR
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City | SPRING LAKE
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State | MI
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Zip | 49456-9243
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Country | US
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Telephone | 616-502-0069
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Fax |
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Provider Business Mailing Address
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Address Line | 15666 RIVER SIDE DR
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City | SPRING LAKE
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State | MI
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Zip | 49456-9243
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Country | US
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Telephone | 616-502-0069
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK A VENTOCILLA
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Credential | OD
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Telephone | 616-502-0069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901003734
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License Number State | MI
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