Organization
GRAND RAPIDS VISION THERAPY LLC
Active
Organization
GRAND RAPIDS VISION THERAPY LLC
Active
Other names
Wow Vision Therapy
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES IAN FORTENBACHER (CFO)
(616) 447-1444
Entity
Organization
Contact information
Practice address
3152 PEREGRINE DR NE STE C205, GRAND RAPIDS, MI 49525-9723
(616) 447-1444
Mailing address
3152 PEREGRINE DR NE STE C205, GRAND RAPIDS, MI 49525-9723
(616) 447-1444
Taxonomy
Speciality
Code
Description
License number
State
152WS0006X
Sports Vision Optometrist
—
—
152WV0400X
Vision Therapy Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4901002693
OPTOMETRY LICENSE
MI
01
—
4901004973
OPTOMETRY LICENSE
MI
Enumeration date
11/28/2018
Last updated
11/28/2018
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