Healthcare Provider Details

I. General information

NPI: 1396715199
Provider Name (Legal Business Name): BRENT OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 1000
GRAND RAPIDS MI
49503-2561
US

IV. Provider business mailing address

25 MICHIGAN ST NE SUITE 1000
GRAND RAPIDS MI
49503-2561
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-1951
  • Fax: 616-458-2089
Mailing address:
  • Phone: 616-458-1951
  • Fax: 616-458-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRENT W. BALKEMA
Title or Position: OWNER
Credential:
Phone: 616-458-1951