MEDICARE: SAINT JOSEPH VISION THERAPY 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	152WS0006X	Sports Vision Optometrist
2	152WV0400X	Vision Therapy Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900A165280	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN
2	4901002693	OTHER	MI	OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1669937926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT JOSEPH VISION THERAPY LLC

Provider Business Mailing Address
First Line	:	2908 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:	269-983-3309
Fax Number	:	269-983-0846

Provider Business Practice Location Address
First Line	:	2908 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:	269-983-3309
Fax Number	:	269-983-0846

Authorized Official
Title or Position	:	CFO
Name	:	MR. CHARLES FORTENBACHER
Credential	:
Telephone Number	:	269-449-1513

Provider Enumeration Date	:	01/31/2019
Last Update Date	:	01/31/2019

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Directions to “SAINT JOSEPH VISION THERAPY LLC ” Practice Location

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