Provider Demographics
NPI:1871739516
Name:PASQUA LLC
Entity type:Organization
Organization Name:PASQUA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HIBNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-724-7440
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-0563
Mailing Address - Country:US
Mailing Address - Phone:989-345-3680
Mailing Address - Fax:989-345-4019
Practice Address - Street 1:511 E HOUGHTON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1185
Practice Address - Country:US
Practice Address - Phone:989-345-3680
Practice Address - Fax:989-345-4019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASQUA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-31
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C510530OtherBLUE CROSS BLUE SHIELD
MI900C510530OtherBLUE CROSS BLUE SHIELD
MIOP63290Medicare PIN