MEDICARE: PRIMARY VISION CENTER

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	4901002288	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900G665050	OTHER	MI	BCBS OF MI

General Provider Information

NPI Number	:	1568642957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY VISION CENTER

Provider Business Mailing Address
First Line	:	33 W SANILAC RD
Second Line	:	PO BOX 112
City	:	SANDUSKY
State	:	MI
Zip	:	48471-1036
Country	:	US
Telephone Number	:	810-648-4242
Fax Number	:	810-648-4248

Provider Business Practice Location Address
First Line	:	33 W SANILAC RD
Second Line	:
City	:	SANDUSKY
State	:	MI
Zip	:	48471-1036
Country	:	US
Telephone Number	:	810-648-4242
Fax Number	:	810-648-4248

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE WILLIAM MCNIVEN
Credential	:	OD
Telephone Number	:	810-648-4242

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	11/14/2007

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