Provider Demographics
NPI:1336849074
Name:GRO OPTICAL, LLC
Entity Type:Organization
Organization Name:GRO OPTICAL, LLC
Other - Org Name:MICHIGAN OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-227-2600
Mailing Address - Street 1:511 WILSON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-7986
Mailing Address - Country:US
Mailing Address - Phone:616-301-8663
Mailing Address - Fax:
Practice Address - Street 1:511 WILSON AVE NW STE E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-7986
Practice Address - Country:US
Practice Address - Phone:616-301-8663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier