Healthcare Provider Details

I. General information

NPI: 1639280951
Provider Name (Legal Business Name): ROBERT B GRILL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 SHOSHONE ST E
TWIN FALLS ID
83301-6336
US

IV. Provider business mailing address

844 SHOSHONE ST E
TWIN FALLS ID
83301-6336
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-9800
  • Fax: 208-734-9433
Mailing address:
  • Phone: 208-734-9800
  • Fax: 208-734-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP0628
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: