Basic Information
| Provider Information | |||||||||
| NPI: | 1649930496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SVS VISION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 CASS AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2107 E BELTLINE AVE NE STE D-E | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163203690 | ||||||||
| FaxNumber: | 6163669065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRESHNEY | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5864641479 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1194879023 | 05 | MI | MEDICAID |