Provider Demographics
NPI:1356896658
Name:GRAND VALLEY OCULAR ANESTHESIA
Entity type:Organization
Organization Name:GRAND VALLEY OCULAR ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:NELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-254-1686
Mailing Address - Street 1:2754 COMPASS DR
Mailing Address - Street 2:STE 170
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8714
Mailing Address - Country:US
Mailing Address - Phone:970-254-1686
Mailing Address - Fax:
Practice Address - Street 1:1000 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8180
Practice Address - Country:US
Practice Address - Phone:970-254-1686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38177207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty