Provider Demographics
NPI:1346708799
Name:GROSE, TORY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TORY
Middle Name:
Last Name:GROSE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18450 COUNTY ROAD 3560
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0101
Mailing Address - Country:US
Mailing Address - Phone:918-841-6826
Mailing Address - Fax:
Practice Address - Street 1:2701 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1901
Practice Address - Country:US
Practice Address - Phone:918-841-6826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK710052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer