Basic Information
| Provider Information | |||||||||
| NPI: | 1659963015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANSEN | ||||||||
| FirstName: | ZACHERY | ||||||||
| MiddleName: | COLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2721 HANNAH BLVD APT 8012 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488236884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195386186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 405 W GREENLAWN AVE STE 200 | ||||||||
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| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486214792 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2021 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | Y | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.