Provider Demographics
NPI:1215157367
Name:CEDAR RUN EYE CENTER OPTICAL
Entity type:Organization
Organization Name:CEDAR RUN EYE CENTER OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCHOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-929-3888
Mailing Address - Street 1:PO BOX 2335
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-2335
Mailing Address - Country:US
Mailing Address - Phone:231-929-3888
Mailing Address - Fax:231-929-4365
Practice Address - Street 1:3830 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8153
Practice Address - Country:US
Practice Address - Phone:231-929-3888
Practice Address - Fax:231-929-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180B86357OtherBCBSM
MI900B863470OtherBCBSM
MI900B863470OtherBCBSM