Provider Demographics
NPI:1891247813
Name:GR DAVICH INC
Entity Type:Organization
Organization Name:GR DAVICH INC
Other - Org Name:DAVICH VISION CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HAERI
Authorized Official - Middle Name:
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-956-6096
Mailing Address - Street 1:2825 28TH ST SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1607
Mailing Address - Country:US
Mailing Address - Phone:616-956-6096
Mailing Address - Fax:606-956-6074
Practice Address - Street 1:2825 28TH ST SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1607
Practice Address - Country:US
Practice Address - Phone:616-956-6096
Practice Address - Fax:606-956-6074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty