Healthcare Provider Details

I. General information

NPI: 1003931601
Provider Name (Legal Business Name): MODERN OPTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4228 29TH ST SE
GRAND RAPIDS MI
49512-1936
US

IV. Provider business mailing address

4228 29TH ST SE
GRAND RAPIDS MI
49512-1936
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-5860
  • Fax:
Mailing address:
  • Phone: 616-949-5860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002933
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004140
License Number StateMI

VIII. Authorized Official

Name: MR. VINCE CONENS
Title or Position: PRESIDENT
Credential:
Phone: 616-949-5860