Healthcare Provider Details

I. General information

NPI: 1891247813
Provider Name (Legal Business Name): GR DAVICH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 28TH ST SE SUITE B
GRAND RAPIDS MI
49512-1607
US

IV. Provider business mailing address

2825 28TH ST SE SUITE B
GRAND RAPIDS MI
49512-1607
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-6096
  • Fax: 606-956-6074
Mailing address:
  • Phone: 616-956-6096
  • Fax: 606-956-6074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HAERI JANG
Title or Position: MANAGER
Credential:
Phone: 616-956-6096