Healthcare Provider Details

I. General information

NPI: 1568932994
Provider Name (Legal Business Name): GRAND RAPIDS VISION THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES IAN FORTENBACHER
Title or Position: CFO
Credential:
Phone: 616-447-1444