Provider Demographics
NPI:1639257553
Name:GOODWILL OPTICAL LLC
Entity Type:Organization
Organization Name:GOODWILL OPTICAL LLC
Other - Org Name:GOODWILL OPTICAL
Other - Org Type:Doing Business As
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 1:1112 ROBBINS RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2740
Practice Address - Country:US
Practice Address - Phone:616-604-5333
Practice Address - Fax:616-604-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID
MIP32620002Medicare PIN
MIU82022Medicare UPIN
MIU88901Medicare UPIN
MI=========OtherTAX ID