Provider Demographics
NPI:1245301852
Name:MRG INC
Entity type:Organization
Organization Name:MRG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GRAVALIN
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC OPTICIAN
Authorized Official - Phone:701-232-1161
Mailing Address - Street 1:2810 NORTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1420
Mailing Address - Country:US
Mailing Address - Phone:701-232-1161
Mailing Address - Fax:
Practice Address - Street 1:2810 NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1420
Practice Address - Country:US
Practice Address - Phone:701-232-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4016040001Medicare ID - Type Unspecified