Provider Demographics
NPI:1730312174
Name:GROVER VISION, PLLC
Entity Type:Organization
Organization Name:GROVER VISION, PLLC
Other - Org Name:GROVER VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-252-0438
Mailing Address - Street 1:7110 S MINGO RD
Mailing Address - Street 2:#108
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3269
Mailing Address - Country:US
Mailing Address - Phone:918-252-0438
Mailing Address - Fax:918-250-0422
Practice Address - Street 1:7110 S MINGO RD
Practice Address - Street 2:#108
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3269
Practice Address - Country:US
Practice Address - Phone:918-252-0438
Practice Address - Fax:918-250-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2527261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200227160AMedicaid
OK200227160AMedicaid
OK6367900001Medicare NSC