MEDICARE: GRAND RAPIDS VISION THERAPY LLC

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	152WS0006X	Sports Vision Optometrist
2	152WV0400X	Vision Therapy Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4901002693	OTHER	MI	OPTOMETRY LICENSE
2	4901004973	OTHER	MI	OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1568932994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND RAPIDS VISION THERAPY LLC

Provider Business Mailing Address
First Line	:	3152 PEREGRINE DR NE STE C205
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-447-1444
Fax Number	:

Provider Business Practice Location Address
First Line	:	3152 PEREGRINE DR NE STE C205
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-447-1444
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CHARLES IAN FORTENBACHER
Credential	:
Telephone Number	:	616-447-1444

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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