Healthcare Provider Details

I. General information

NPI: 1083055651
Provider Name (Legal Business Name): GRANT K GWINNER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E 3RD ST SUITE A
ELLSWORTH KS
67439-4224
US

IV. Provider business mailing address

801 E 3RD ST SUITE A
ELLSWORTH KS
67439-4224
US

V. Phone/Fax

Practice location:
  • Phone: 785-472-3272
  • Fax: 785-472-3360
Mailing address:
  • Phone: 785-472-3272
  • Fax: 785-472-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1950
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: