Provider Demographics
NPI:1073727590
Name:JOANNE GRONQUIST, O.D.
Entity Type:Organization
Organization Name:JOANNE GRONQUIST, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-569-1504
Mailing Address - Street 1:1805 STATE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-8415
Mailing Address - Country:US
Mailing Address - Phone:805-569-1504
Mailing Address - Fax:805-569-8707
Practice Address - Street 1:1805 STATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-8415
Practice Address - Country:US
Practice Address - Phone:805-569-1504
Practice Address - Fax:805-569-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10965T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5358150001Medicare NSC
CAW19637Medicare PIN