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General NPI Number Information
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NPI Number | 1730583972
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Entity Type | Organization
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Legal Business Name | WYOMING FAMILY VISION CARE LLC
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 1391 36TH ST SW
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City | WYOMING
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State | MI
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Zip | 49509-3417
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Country | US
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Telephone | 616-538-5420
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Fax | 616-538-7288
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Provider Business Mailing Address
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Address Line | 1391 36TH ST SW
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City | WYOMING
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State | MI
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Zip | 49509-3417
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Country | US
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Telephone | 616-538-5420
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Fax | 616-538-7288
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Authorized Official
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Title or Position | OPTICIAN
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Name | MRS. LAURA CRISPINA REYES
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Credential |
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Telephone | 616-538-5420
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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 | 4901004597
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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 | 4901004759
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License Number State | MI
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