MEDICARE: KENT VISION CENTERS 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	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900F111210	OTHER	MI	BCBS OF MI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336224682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENT VISION CENTERS INC

Provider Business Mailing Address
First Line	:	105 W EXCHANGE ST
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-2024
Country	:	US
Telephone Number	:	616-846-0620
Fax Number	:	616-844-6079

Provider Business Practice Location Address
First Line	:	4022 PLAINFIELD AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1608
Country	:	US
Telephone Number	:	616-363-1868
Fax Number	:	616-363-2246

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TIMOTHY D WESTRA
Credential	:
Telephone Number	:	616-846-0620

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	02/23/2009

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