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General NPI Number Information
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NPI Number | 1619315926
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Entity Type | Organization
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Legal Business Name | CHARLEVOIX EYE CENTER, P.C.
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Dates
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Enumeration Date | 06/08/2013
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 1008 BRIDGE ST
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City | CHARLEVOIX
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State | MI
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Zip | 49720-1602
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Country | US
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Telephone | 231-547-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 1008 BRIDGE ST
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City | CHARLEVOIX
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State | MI
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Zip | 49720-1602
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JON VANWAGNEN
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Credential | O.D.
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Telephone | 989-916-6168
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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 | 4901004725
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License Number State | MI
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