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General NPI Number Information
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NPI Number | 1003931601
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Entity Type | Organization
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Legal Business Name | MODERN OPTICS, INC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 09/18/2009
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Provider Practice Location Address
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Address Line | 4228 29TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-1936
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Country | US
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Telephone | 616-949-5860
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Fax |
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Provider Business Mailing Address
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Address Line | 4228 29TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-1936
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Country | US
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Telephone | 616-949-5860
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. VINCE CONENS
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Credential |
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Telephone | 616-949-5860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901002933
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901004140
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License Number State | MI
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