Provider Demographics
NPI:1437182284
Name:GROVES, LISA K (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:GROVES
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:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-2347
Mailing Address - Country:US
Mailing Address - Phone:573-365-3717
Mailing Address - Fax:573-365-4485
Practice Address - Street 1:3251 BAGNELL DAM BLVD STE D
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9745
Practice Address - Country:US
Practice Address - Phone:573-365-3717
Practice Address - Fax:573-365-4485
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029538152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOVO3438Medicare UPIN
MO2574513045Medicare ID - Type Unspecified