Basic Information
| Provider Information | |||||||||
| NPI: | 1083926984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JANSMA FAMILY EYE CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5491 DIVISION AVE S | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495485720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162613939 | ||||||||
| FaxNumber: | 6162613940 | ||||||||
| Practice Location | |||||||||
| Address1: | 5491 DIVISION AVE S | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495485720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162613939 | ||||||||
| FaxNumber: | 6162613940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | JANSMA | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6162613939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003272 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 900D16699 | 01 | MI | BLUE CROSS BLUE SHIELD OF MI | OTHER |