=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902194970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY EYE AND VISION CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2011
-----------------------------------------------------
Last Update Date | 11/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1191 BYRON RD
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48843-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-546-4655
-----------------------------------------------------
Fax | 517-546-0899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1191 BYRON RD
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48843-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-546-4655
-----------------------------------------------------
Fax | 517-546-0899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JOSEPH SAMUEL CONRAD
-----------------------------------------------------
Credential | OD, MS
-----------------------------------------------------
Telephone | 863-368-0502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004635
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------