Provider Demographics
NPI:1699051193
Name:NORTHERN EYE CARE ASSOCIATES, P.C.
Entity type:Organization
Organization Name:NORTHERN EYE CARE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:POQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-774-8280
Mailing Address - Street 1:200 FAIRBANKS ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-1510
Mailing Address - Country:US
Mailing Address - Phone:906-774-8280
Mailing Address - Fax:906-774-8290
Practice Address - Street 1:200 FAIRBANKS ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-1510
Practice Address - Country:US
Practice Address - Phone:906-774-8280
Practice Address - Fax:906-774-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B20055OtherBCBSM
MI6891720001OtherMEDICARE DMEPOS
MIDS9268Medicare PIN
MI0B20055OtherBCBSM