Provider Demographics
NPI:1154452829
Name:GRO OPTICAL, LLC
Entity Type:Organization
Organization Name:GRO OPTICAL, LLC
Other - Org Name:GRAND RAPIDS OPTICIANS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-227-2600
Mailing Address - Street 1:750 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6049
Mailing Address - Country:US
Mailing Address - Phone:616-942-1350
Mailing Address - Fax:616-949-1670
Practice Address - Street 1:705 S GREENVILLE WEST DR STE 201
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3531
Practice Address - Country:US
Practice Address - Phone:616-754-5667
Practice Address - Fax:616-754-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540D105120OtherBCBS OF MI