Provider Demographics
NPI:1053534040
Name:GRAND RAPIDS EYE CARE 2820 PLLC
Entity type:Organization
Organization Name:GRAND RAPIDS EYE CARE 2820 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:COLIN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-363-5413
Mailing Address - Street 1:2820 E BELTLINE LN NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9432
Mailing Address - Country:US
Mailing Address - Phone:616-363-5413
Mailing Address - Fax:616-363-4211
Practice Address - Street 1:2820 E BELTLINE LN NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9432
Practice Address - Country:US
Practice Address - Phone:616-363-5413
Practice Address - Fax:616-363-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1122530001Medicare NSC
MIOD14801Medicare PIN
MICC2350Medicare PIN