Provider Demographics
NPI:1477835700
Name:OLIVER, GRANT
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:OLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BRICKSTONE SQ
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1492
Mailing Address - Country:US
Mailing Address - Phone:978-662-5273
Mailing Address - Fax:888-908-3211
Practice Address - Street 1:300 BRICKSTONE SQ
Practice Address - Street 2:SUITE 201
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-1492
Practice Address - Country:US
Practice Address - Phone:978-662-5273
Practice Address - Fax:888-908-3211
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6095156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician