Provider Demographics
NPI:1699816124
Name:COOPERSVILLE VISION CENTER PC
Entity Type:Organization
Organization Name:COOPERSVILLE VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-837-6847
Mailing Address - Street 1:692 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1306
Mailing Address - Country:US
Mailing Address - Phone:616-837-6847
Mailing Address - Fax:616-837-9338
Practice Address - Street 1:692 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1306
Practice Address - Country:US
Practice Address - Phone:616-837-6847
Practice Address - Fax:616-837-9338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0879000001Medicare NSC
MI0N55960Medicare PIN