MEDICARE: MODERN OPTICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1184748840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN OPTICS, INC.

Provider Business Mailing Address
First Line	:	4228 29TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1936
Country	:	US
Telephone Number	:	616-949-5860
Fax Number	:

Provider Business Practice Location Address
First Line	:	4228 29TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1936
Country	:	US
Telephone Number	:	616-949-5860
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. VINCENT CONENS
Credential	:
Telephone Number	:	616-949-5860

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	04/18/2008

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Directions to “MODERN OPTICS, INC. ” Practice Location

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