Provider Demographics
NPI:1992133169
Name:GROUP VISION CENTER, INC.
Entity type:Organization
Organization Name:GROUP VISION CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J
Authorized Official - Last Name:CUKROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-352-2806
Mailing Address - Street 1:4337 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3535
Mailing Address - Country:US
Mailing Address - Phone:313-582-8080
Mailing Address - Fax:313-582-8090
Practice Address - Street 1:4337 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3535
Practice Address - Country:US
Practice Address - Phone:313-582-8080
Practice Address - Fax:313-582-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003927152W00000X, 152WC0802X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15956Medicare PIN