=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881754406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERIDIAN EYE CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 12/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1669 HAMILTON RD STE 200
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-349-4743
-----------------------------------------------------
Fax | 517-349-0096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1669 HAMILTON RD STE 200
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-349-4743
-----------------------------------------------------
Fax | 517-349-0096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AMANDA B GORSLINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-349-4743
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | AH004261
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | AG004143
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------