Provider Demographics
NPI:1083230858
Name:GRANVILLE VISION CENTER LLC
Entity Type:Organization
Organization Name:GRANVILLE VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-361-0954
Mailing Address - Street 1:1876 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1133
Mailing Address - Country:US
Mailing Address - Phone:614-361-0954
Mailing Address - Fax:
Practice Address - Street 1:205 1/2 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-1423
Practice Address - Country:US
Practice Address - Phone:614-361-0954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty