1942331681 NPI number — GRO OPTICAL, LLC

Table of content: (NPI 1942331681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942331681 NPI number — GRO OPTICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRO OPTICAL, 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:
6
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:
1942331681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 E BELTLINE AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525-6049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-942-1350
Provider Business Mailing Address Fax Number:
616-949-1670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 68TH ST SE
Provider Second Line Business Practice Location Address:
SPECTRUM SOUTH
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49548-6980
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-827-0003
Provider Business Practice Location Address Fax Number:
616-588-6519
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCRANN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
636-227-2600

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 540D105120 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com