Healthcare Provider Details

I. General information

NPI: 1063759678
Provider Name (Legal Business Name): KELLY BORGMAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 WASHINGTON AVE STE 120
HOLLAND MI
49423-7724
US

IV. Provider business mailing address

904 WASHINGTON AVE STE 120
HOLLAND MI
49423-7724
US

V. Phone/Fax

Practice location:
  • Phone: 616-796-9995
  • Fax:
Mailing address:
  • Phone: 616-796-9995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1910DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1910DT
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901005784
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: