MEDICARE: WORLD WIDE VISION THERAPY CENTERS, L.L.C.

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	152WV0400X	Vision Therapy Optometrist	4901004791	MI
2	152WV0400X	Vision Therapy Optometrist	4901004454	MI
3	152W00000X	Optometrist	4901002693	MI
4	152WS0006X	Sports Vision Optometrist	4901002693	MI
5	152WV0400X	Vision Therapy Optometrist	4901002693	MI

Other Identifiers

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

General Provider Information

NPI Number	:	1801275193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WORLD WIDE VISION THERAPY CENTERS, L.L.C.

Provider Business Mailing Address
First Line	:	3152 PEREGRINE DR NE
Second Line	:	SUITE C205
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-447-1444
Fax Number	:

Provider Business Practice Location Address
First Line	:	3152 PEREGRINE DR NE
Second Line	:	SUITE C205
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-447-1444
Fax Number	:	616-447-1445

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAN L FORTENBACHER
Credential	:	O.D.
Telephone Number	:	269-983-3309

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	05/21/2015

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Directions to “WORLD WIDE VISION THERAPY CENTERS, L.L.C. ” Practice Location

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