Healthcare Provider Details

I. General information

NPI: 1407548548
Provider Name (Legal Business Name): REBECCA J COLBURN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5859 28TH ST SE
GRAND RAPIDS MI
49546-6905
US

IV. Provider business mailing address

10260 JORDAN RIVER DR SE
ALTO MI
49302-9189
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-5125
  • Fax: 616-949-5843
Mailing address:
  • Phone: 616-724-7641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. REBECCA J COLBURN
Title or Position: OWNER
Credential: OD
Phone: 616-724-7641