Provider Demographics
NPI:1003931601
Name:MODERN OPTICS, INC
Entity Type:Organization
Organization Name:MODERN OPTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-949-5860
Mailing Address - Street 1:4228 29TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1936
Mailing Address - Country:US
Mailing Address - Phone:616-949-5860
Mailing Address - Fax:
Practice Address - Street 1:4228 29TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1936
Practice Address - Country:US
Practice Address - Phone:616-949-5860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002933152W00000X
MI4901004140152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D11540-0OtherBLUE CROSS - EXAMS