MEDICARE: CARLIE CRANK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901005677	MI

General Provider Information

NPI Number	:	1568152239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLIE CRANK

Provider Business Mailing Address
First Line	:	6748 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7032
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6748 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7032
Country	:	US
Telephone Number	:	616-275-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	06/21/2023

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Directions to “ CARLIE CRANK ” Practice Location

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