Healthcare Provider Details

I. General information

NPI: 1447542485
Provider Name (Legal Business Name): GOODWILL OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 MILLER RD SUITE A
FLINT MI
48507-1297
US

IV. Provider business mailing address

105 W EXCHANGE ST
SPRING LAKE MI
49456-2024
US

V. Phone/Fax

Practice location:
  • Phone: 810-230-0045
  • Fax: 810-230-0045
Mailing address:
  • Phone: 616-846-0620
  • Fax: 616-844-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003723
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY D WESTRA
Title or Position: PRESIDENT
Credential:
Phone: 616-846-0620