Organization
SAINT JOSEPH VISION THERAPY LLC
Active
Other names
Wow Vision Therapy
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHARLES FORTENBACHER (CFO)
(269) 449-1513
Entity
Organization
Contact information
Practice address
2908 DIVISION ST, SAINT JOSEPH, MI 49085-2437
(269) 983-3309
(269) 983-0846
Mailing address
2908 DIVISION ST, SAINT JOSEPH, MI 49085-2437
(269) 983-3309
(269) 983-0846
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
—
900A165280
BLUE CROSS BLUE SHIELD OF MICHIGAN
MI
Enumeration date
01/31/2019
Last updated
01/31/2019
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