Provider Demographics
NPI:1548628415
Name:ACADEMY OF VISION DEVELOPMENT, PLLC
Entity type:Organization
Organization Name:ACADEMY OF VISION DEVELOPMENT, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-485-9804
Mailing Address - Street 1:6617 CROSSINGS DR SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7378
Mailing Address - Country:US
Mailing Address - Phone:616-541-7080
Mailing Address - Fax:616-541-7088
Practice Address - Street 1:6617 CROSSINGS DR SE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7378
Practice Address - Country:US
Practice Address - Phone:616-541-7080
Practice Address - Fax:616-541-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004369152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty