Provider Demographics
NPI:1124338736
Name:SWAN OPTOMETRY SERVICES, PC
Entity type:Organization
Organization Name:SWAN OPTOMETRY SERVICES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MED
Authorized Official - Phone:616-866-3077
Mailing Address - Street 1:25 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1281
Mailing Address - Country:US
Mailing Address - Phone:616-866-3077
Mailing Address - Fax:616-866-4408
Practice Address - Street 1:25 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1281
Practice Address - Country:US
Practice Address - Phone:616-866-3077
Practice Address - Fax:616-866-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003186152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900006367OtherPRIORITY HEALTH
MI4401840Medicaid
MI999998001OtherVSP
MIM5003186OtherBLUE CROSS
MIE47602037Medicare PIN
MIU13534Medicare UPIN
MI4401840Medicaid