Basic Information
| Provider Information | |||||||||
| NPI: | 1811190960 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOODWILL OPTICAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOODWILL 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: | G3525 S SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485291260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107446505 | ||||||||
| FaxNumber: | 8107446506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| 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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
No ID Information.