Provider Demographics
NPI:1396919494
Name:JOHN S GRAVES OD PLC
Entity type:Organization
Organization Name:JOHN S GRAVES OD PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD PLC
Authorized Official - Phone:989-846-4197
Mailing Address - Street 1:105 N GROVE ST
Mailing Address - Street 2:PO BOX 576
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-0576
Mailing Address - Country:US
Mailing Address - Phone:989-846-4197
Mailing Address - Fax:989-846-4989
Practice Address - Street 1:105 N GROVE ST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-0576
Practice Address - Country:US
Practice Address - Phone:989-846-4197
Practice Address - Fax:989-846-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003143332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier