1043422769 NPI number — GRENE VISION GROUP LLC

Table of content: (NPI 1043422769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043422769 NPI number — GRENE VISION GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRENE VISION GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043422769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1851 N WEBB RD
Provider Second Line Business Mailing Address:
ATTN FLR2
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67206-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-636-2010
Provider Business Mailing Address Fax Number:
316-691-4408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1277 N MAIZE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-722-8883
Provider Business Practice Location Address Fax Number:
316-609-4740
Provider Enumeration Date:
05/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GIRA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
636-227-2600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)