Basic Information
| Provider Information | |||||||||
| NPI: | 1245315589 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENT VISION CENTERS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENT OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | SPRING LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494562024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168460620 | ||||||||
| FaxNumber: | 6168446079 | ||||||||
| Practice Location | |||||||||
| Address1: | 896 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494401250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263635 | ||||||||
| FaxNumber: | 2317220608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WESTRA | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6168460620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 30290 | 05 | MI | MEDICAID |