Provider Demographics
NPI:1881090041
Name:KENTWOOD FAMILY EYE CARE
Entity type:Organization
Organization Name:KENTWOOD FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLION
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-949-7442
Mailing Address - Street 1:4326 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1908
Mailing Address - Country:US
Mailing Address - Phone:616-949-7442
Mailing Address - Fax:616-956-1274
Practice Address - Street 1:2073 DYKSTRA RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1988
Practice Address - Country:US
Practice Address - Phone:231-750-0845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU88901Medicare UPIN
MIU86989Medicare UPIN