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General NPI Number Information
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NPI Number | 1881090041
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Entity Type | Organization
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Legal Business Name | KENTWOOD FAMILY EYE CARE
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Dates
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Enumeration Date | 11/14/2014
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Last Update Date | 11/14/2014
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Provider Practice Location Address
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Address Line | 2073 DYKSTRA RD
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City | MUSKEGON
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State | MI
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Zip | 49445-1988
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Country | US
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Telephone | 231-750-0845
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Fax |
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Provider Business Mailing Address
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Address Line | 4326 28TH ST SE
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City | KENTWOOD
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State | MI
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Zip | 49512-1908
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Country | US
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Telephone | 616-949-7442
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Fax | 616-956-1274
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | BRUCE BULLION
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Credential | O.D.
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Telephone | 616-949-7442
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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 | 4901004094
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License Number State | MI
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