MEDICARE: ALLENDALE FAMILY VISION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004659	MI

General Provider Information

NPI Number	:	1639467962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLENDALE FAMILY VISION LLC

Provider Business Mailing Address
First Line	:	6101 LAKE MICHIGAN DR
Second Line	:	STE B700
City	:	ALLENDALE
State	:	MI
Zip	:	49401-9215
Country	:	US
Telephone Number	:	616-895-2020
Fax Number	:	616-895-2060

Provider Business Practice Location Address
First Line	:	6101 LAKE MICHIGAN DR
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-9215
Country	:	US
Telephone Number	:	616-895-2020
Fax Number	:	616-895-2060

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NICHOLAS VIJAY LILLIE
Credential	:	O.D.
Telephone Number	:	616-895-2020

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	05/02/2013

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