Healthcare Provider Details

I. General information

NPI: 1790106136
Provider Name (Legal Business Name): RX OPTICAL LABORATORIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 BRETON RD SE
GRAND RAPIDS MI
49506-4869
US

IV. Provider business mailing address

1700 S PARK ST
KALAMAZOO MI
49001-2779
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-2993
  • Fax: 616-957-9253
Mailing address:
  • Phone: 269-342-0003
  • Fax: 269-342-4284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003762
License Number StateMI

VIII. Authorized Official

Name: STEVEN W YONKE
Title or Position: CFO
Credential:
Phone: 269-342-0003