Basic Information
| Provider Information | |||||||||
| NPI: | 1760668016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESHORE EYECARE CENTER P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11971 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494249610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163950606 | ||||||||
| FaxNumber: | 6163950077 | ||||||||
| Practice Location | |||||||||
| Address1: | 11971 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494249610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163950606 | ||||||||
| FaxNumber: | 6163950077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROUBOS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 6163950606 | ||||||||
| 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 | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3494254 | 05 | MI | MEDICAID |