MEDICARE: PREMIER FAMILY EYE CARE PC.

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		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851759716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER FAMILY EYE CARE PC.

Provider Business Mailing Address
First Line	:	6748 KALAMZOO AVE S.E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7032
Country	:	US
Telephone Number	:	616-633-0574
Fax Number	:

Provider Business Practice Location Address
First Line	:	6748 KALAMZOO AVE S.E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7032
Country	:	US
Telephone Number	:	616-633-0574
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAY JOSEPH CRANK
Credential	:	O.D
Telephone Number	:	616-633-0574

Provider Enumeration Date	:	02/08/2016
Last Update Date	:	02/08/2016

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