Healthcare Provider Details

I. General information

NPI: 1417365339
Provider Name (Legal Business Name): CYNTHIA GENEVA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 JACKSON AVE STE A
GRAND HAVEN MI
49417-1067
US

IV. Provider business mailing address

333 JACKSON AVE STE A
GRAND HAVEN MI
49417-1067
US

V. Phone/Fax

Practice location:
  • Phone: 616-201-2020
  • Fax: 616-317-2545
Mailing address:
  • Phone: 616-201-2020
  • Fax: 616-317-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901004836
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901004836
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004836
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: