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General NPI Number Information
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NPI Number | 1558159046
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Entity Type | Individual
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Provider Name | TRAVIS BETHKE
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Gender | Male
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Dates
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Enumeration Date | 04/25/2025
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Last Update Date | 06/04/2025
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Provider Practice Location Address
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Address Line | 1700 S DRAKE RD STE D
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City | KALAMAZOO
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State | MI
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Zip | 49006-5721
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Country | US
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Telephone | 269-888-4320
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Fax |
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Provider Business Mailing Address
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Address Line | 2063 LAURIE LN
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City | HOLLAND
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State | MI
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Zip | 49424-9082
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Country | US
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Telephone | 616-879-9381
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4901005879
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License Number State | MI
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