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General NPI Number Information
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NPI Number | 1417137084
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Entity Type | Organization
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Legal Business Name | FAMILY & PEDIATRIC EYE CARE PLC
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Dates
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Enumeration Date | 11/12/2007
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 144 MONROE CENTER
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2802
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Country | US
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Telephone | 616-459-0641
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Fax | 616-459-0621
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Provider Business Mailing Address
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Address Line | 144 MONROE CTR NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2802
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Country | US
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Telephone | 616-459-0641
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Fax | 616-459-0621
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Authorized Official
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Title or Position | STORE OWNER
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Name | MR. GENE ERNEST FONGER
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Credential | OD
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Telephone | 616-459-0641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 4901002505
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 4901004219
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | 4901004219
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License Number State | MI
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