Healthcare Provider Details

I. General information

NPI: 1801275193
Provider Name (Legal Business Name): WORLD WIDE VISION THERAPY CENTERS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 PEREGRINE DR NE SUITE C205
GRAND RAPIDS MI
49525-9723
US

IV. Provider business mailing address

3152 PEREGRINE DR NE SUITE C205
GRAND RAPIDS MI
49525-9723
US

V. Phone/Fax

Practice location:
  • Phone: 616-447-1444
  • Fax: 616-447-1445
Mailing address:
  • Phone: 616-447-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002693
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number4901002693
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901002693
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901004791
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4901004454
License Number StateMI

VIII. Authorized Official

Name: DR. DAN L FORTENBACHER
Title or Position: OWNER
Credential: O.D.
Phone: 269-983-3309