Provider Demographics
NPI:1467479212
Name:ADA VISION CENTER PLLC
Entity Type:Organization
Organization Name:ADA VISION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SINCE 1977
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:REYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-676-1283
Mailing Address - Street 1:596 ADA DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8465
Mailing Address - Country:US
Mailing Address - Phone:616-676-1283
Mailing Address - Fax:616-676-9133
Practice Address - Street 1:596 ADA DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8465
Practice Address - Country:US
Practice Address - Phone:616-676-1283
Practice Address - Fax:616-676-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4140369Medicaid
MI1264970001Medicare NSC
MI0M77760Medicare ID - Type Unspecified
MI4140369Medicaid