=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275045916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W. OPTICAL 4 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2017
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1004 28TH ST SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49509-2881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 444-393-3928
-----------------------------------------------------
Fax | 844-439-3392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3233 ALPINE AVE NW STE A
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49544-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-432-3591
-----------------------------------------------------
Fax | 616-432-3597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | W-HOLDING LLC CEO
-----------------------------------------------------
Name | AARON WINTERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-512-4992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------