Provider Demographics
NPI:1124018916
Name:GROVER, LORI L (OD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:GROVER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4726
Mailing Address - Country:US
Mailing Address - Phone:480-890-0468
Mailing Address - Fax:480-835-0912
Practice Address - Street 1:1520 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4725
Practice Address - Country:US
Practice Address - Phone:480-890-0468
Practice Address - Fax:480-835-0912
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1332152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU55786Medicare UPIN