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General NPI Number Information
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NPI Number | 1497812150
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Entity Type | Organization
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Legal Business Name | THREE RIVERS EYECARE PC
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 07/20/2010
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Provider Practice Location Address
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Address Line | 123 S FAIR STREET
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City | OTSEGO
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State | MI
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Zip | 49078
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Country | US
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Telephone | 269-694-9462
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Fax | 269-694-5826
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Provider Business Mailing Address
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Address Line | 56847 N MAIN ST
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City | THREE RIVERS
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State | MI
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Zip | 49036
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Country | US
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Telephone | 269-273-5825
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Fax | 269-279-6010
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Authorized Official
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Title or Position | PRESIDENT OWNER
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Name | MICHAEL L SUSSEX
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Credential | OD
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Telephone | 269-694-9462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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