Organization
ELDER EYE CARE GROUP PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK A VENTOCILLA OD (PRESIDENT)
(616) 502-0069
Entity
Organization
Contact information
Practice address
15666 RIVER SIDE DR, SPRING LAKE, MI 49456-9243
(616) 502-0069
Mailing address
15666 RIVER SIDE DR, SPRING LAKE, MI 49456-9243
(616) 502-0069
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
4901003734
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4820570
—
MI
01
—
900029831
PRIORITY HEALTH
MI
01
—
90G011590
BLUE CROSS BLUE SHIELD
MI
01
—
P00329735
RR MEDICARE NUMBER
MI
Enumeration date
12/21/2006
Last updated
09/14/2012
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