1801275193 NPI number — WORLD WIDE VISION THERAPY CENTERS, L.L.C.

Table of content: (NPI 1801275193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801275193 NPI number — WORLD WIDE VISION THERAPY CENTERS, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORLD WIDE VISION THERAPY CENTERS, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801275193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3152 PEREGRINE DR NE
Provider Second Line Business Practice Location Address:
SUITE C205
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-9723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-447-1444
Provider Business Practice Location Address Fax Number:
616-447-1445
Provider Enumeration Date:
05/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FORTENBACHER
Authorized Official First Name:
DAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-983-3309

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  4901004791 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 4901004454 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4901002693 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: 4901002693 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 4901002693 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 900A165280 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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