Provider Demographics
NPI:1811109051
Name:GOODWILL OPTICAL INC
Entity type:Organization
Organization Name:GOODWILL OPTICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-846-0620
Mailing Address - Street 1:105 W EXCHANGE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:282 12TH ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-398-9660
Practice Address - Fax:231-398-9671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID
MIP32620001Medicare PIN
MI=========OtherTAX ID
MIU32355Medicare UPIN
MIU37641Medicare UPIN