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General NPI Number Information
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NPI Number | 1770526436
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Entity Type | Organization
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Legal Business Name | LAKEVILLE EYE CARE CENTER, INC.
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 01/17/2013
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Provider Practice Location Address
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Address Line | 9575 STATE RD
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City | MILLINGTON
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State | MI
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Zip | 48746-9482
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Country | US
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Telephone | 989-871-9552
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Fax | 989-871-9554
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Provider Business Mailing Address
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Address Line | 9575 STATE RD
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City | MILLINGTON
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State | MI
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Zip | 48746-9482
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Country | US
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Telephone | 989-871-9552
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Fax | 989-871-9554
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Authorized Official
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Title or Position | OWNER
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Name | MRS. TERESA MARIE ENNIS-DECKER
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Credential | O.D.
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Telephone | 989-871-9552
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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 |
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License Number State |
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