Provider Demographics
NPI:1679864110
Name:DR MARIANNE K MOAYER OD PLLC
Entity Type:Organization
Organization Name:DR MARIANNE K MOAYER OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SHARE HOLDER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MOAYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-667-1864
Mailing Address - Street 1:241 COVINGTON CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3297
Mailing Address - Country:US
Mailing Address - Phone:616-667-1864
Mailing Address - Fax:
Practice Address - Street 1:1600 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7024
Practice Address - Country:US
Practice Address - Phone:616-365-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI49010004443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty