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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