Provider Demographics
NPI:1922206531
Name:WYOMING FAMILY VISION CARE PLLC
Entity Type:Organization
Organization Name:WYOMING FAMILY VISION CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHORYAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-538-5420
Mailing Address - Street 1:1391 36TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3417
Mailing Address - Country:US
Mailing Address - Phone:616-538-5420
Mailing Address - Fax:616-538-7288
Practice Address - Street 1:1391 36TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3417
Practice Address - Country:US
Practice Address - Phone:616-538-5420
Practice Address - Fax:616-538-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4821070001Medicare NSC
MI0P01610Medicare ID - Type UnspecifiedMEDICARE GROUP #