Provider Demographics
NPI:1912082298
Name:KENT VISION CENTERS INC
Entity type:Organization
Organization Name:KENT VISION CENTERS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-846-0620
Mailing Address - Street 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:941 BRIDGE ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5555
Practice Address - Country:US
Practice Address - Phone:616-774-2904
Practice Address - Fax:616-774-4053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI(94) 4634162Medicaid
MI900F111210OtherBCBS OF MI
MI(94) 4634171Medicaid
MI(94) 4634162Medicaid
MIP00151224Medicare ID - Type UnspecifiedMEDICARE MEDICARE DOCTOR
MIDC1560Medicare PIN
MIN96840005Medicare ID - Type UnspecifiedMEDICARE DOCTOR NUMBER
MIU30023Medicare UPIN
MI(94) 4634171Medicaid
MI=========OtherTAX ID
MI(94) 4634162Medicaid
MI900F111210OtherBCBS OF MI
MIP00263602Medicare ID - Type UnspecifiedRAILROAD MEDICARE DOCTOR
MI5189400010Medicare NSC