Provider Demographics
NPI:1407038417
Name:GROVE EYE CENTER INC
Entity Type:Organization
Organization Name:GROVE EYE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BURNESS
Authorized Official - Middle Name:R
Authorized Official - Last Name:YANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-786-9777
Mailing Address - Street 1:PO BOX 452529
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-2529
Mailing Address - Country:US
Mailing Address - Phone:918-786-9777
Mailing Address - Fax:918-786-8458
Practice Address - Street 1:1013 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2847
Practice Address - Country:US
Practice Address - Phone:918-786-9777
Practice Address - Fax:918-786-8458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK970152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
OK2608152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
731086218001OtherBLUE CROSS BLUE SHIELD
OK100763110AMedicaid
OK1407038417OtherADVANTRA FREEDOM
410010874Medicare PIN
OK1407038417OtherADVANTRA FREEDOM
0445410001Medicare NSC
OK100763110AMedicaid
OKP00609861Medicare PIN
1407038417Medicare PIN