Provider Demographics
NPI:1598114340
Name:GROVE, MORGAN (OD)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:GROVE
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 489
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-0489
Mailing Address - Country:US
Mailing Address - Phone:541-396-4042
Mailing Address - Fax:541-396-6507
Practice Address - Street 1:855 W CENTRAL BLVD STE A
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1290
Practice Address - Country:US
Practice Address - Phone:541-396-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3664ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist