Provider Demographics
NPI:1801275193
Name:WORLD WIDE VISION THERAPY CENTERS, L.L.C.
Entity type:Organization
Organization Name:WORLD WIDE VISION THERAPY CENTERS, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORTENBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-983-3309
Mailing Address - Street 1:3152 PEREGRINE DR NE
Mailing Address - Street 2:SUITE C205
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9723
Mailing Address - Country:US
Mailing Address - Phone:616-447-1444
Mailing Address - Fax:
Practice Address - Street 1:3152 PEREGRINE DR NE
Practice Address - Street 2:SUITE C205
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9723
Practice Address - Country:US
Practice Address - Phone:616-447-1444
Practice Address - Fax:616-447-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004791152WV0400X
MI4901004454152WV0400X
MI4901002693152W00000X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A165280OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0700790001Medicare NSC
MIA17615002Medicare PIN
MI900A165280OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIC20444Medicare PIN