Provider Demographics
NPI:1124205547
Name:SOUTH KENT VISION CENTER PC
Entity type:Organization
Organization Name:SOUTH KENT VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:HOHENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-534-4953
Mailing Address - Street 1:4467 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4808
Mailing Address - Country:US
Mailing Address - Phone:616-534-4953
Mailing Address - Fax:
Practice Address - Street 1:4467 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4808
Practice Address - Country:US
Practice Address - Phone:616-534-4953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI943216794Medicaid
MIOD16559OtherBLUE CROSS BLUE SHIELD
MI943216794Medicaid