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General NPI Number Information
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NPI Number | 1780810598
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Entity Type | Organization
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Legal Business Name | CANADIAN LAKES EYECARE, P.L.L.C.
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Dates
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Enumeration Date | 06/08/2009
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Last Update Date | 06/08/2009
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Provider Practice Location Address
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Address Line | 10085 BUCHANAN RD
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City | CANADIAN LAKES
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State | MI
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Zip | 49346-9762
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Country | US
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Telephone | 231-972-3937
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Fax | 231-972-1212
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Provider Business Mailing Address
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Address Line | 10085 BUCHANAN RD
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City | CANADIAN LAKES
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State | MI
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Zip | 49346-9762
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Country | US
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Telephone | 231-972-3937
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Fax | 231-972-1212
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY EVELYN PHILLIPS
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Credential | O.D.
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Telephone | 231-972-3937
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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 | 4901004486
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License Number State | MI
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