Healthcare Provider Details

I. General information

NPI: 1710924261
Provider Name (Legal Business Name): GOODWILL OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/10/2024
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 J MADDY PKWY
INTERLOCHEN MI
49643-9135
US

IV. Provider business mailing address

2720 J MADDY PKWY
INTERLOCHEN MI
49643-9135
US

V. Phone/Fax

Practice location:
  • Phone: 231-932-1520
  • Fax: 231-932-1552
Mailing address:
  • Phone: 231-932-1520
  • Fax: 231-932-1552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN MICHAEL HANCOTTE
Title or Position: PRESIDENT
Credential:
Phone: 231-932-1520