Provider Demographics
NPI:1053488106
Name:GRIN EYECARE OF GRANDVIEW, INC
Entity Type:Organization
Organization Name:GRIN EYECARE OF GRANDVIEW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GORDIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-761-6337
Mailing Address - Street 1:1024 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-2456
Mailing Address - Country:US
Mailing Address - Phone:816-761-6337
Mailing Address - Fax:816-761-3564
Practice Address - Street 1:1024 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2456
Practice Address - Country:US
Practice Address - Phone:816-761-6337
Practice Address - Fax:816-761-3564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017834207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5816860001Medicare NSC
MOQ950000Medicare PIN