Provider Demographics
NPI:1639467962
Name:ALLENDALE FAMILY VISION LLC
Entity Type:Organization
Organization Name:ALLENDALE FAMILY VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:VIJAY
Authorized Official - Last Name:LILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-895-2020
Mailing Address - Street 1:6101 LAKE MICHIGAN DR
Mailing Address - Street 2:STE B700
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9215
Mailing Address - Country:US
Mailing Address - Phone:616-895-2020
Mailing Address - Fax:616-895-2060
Practice Address - Street 1:6101 LAKE MICHIGAN DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9215
Practice Address - Country:US
Practice Address - Phone:616-895-2020
Practice Address - Fax:616-895-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty