Provider Demographics
NPI:1033182936
Name:GRIMSRUD, ROYCE L (OD)
Entity Type:Individual
Prefix:DR
First Name:ROYCE
Middle Name:L
Last Name:GRIMSRUD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-0149
Mailing Address - Country:US
Mailing Address - Phone:605-698-4112
Mailing Address - Fax:605-698-3160
Practice Address - Street 1:121 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-1412
Practice Address - Country:US
Practice Address - Phone:605-698-4112
Practice Address - Fax:605-698-3160
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201690Medicaid
SD0680820001Medicare NSC
SDT66592Medicare UPIN
SD9201690Medicaid