Healthcare Provider Details

I. General information

NPI: 1295940633
Provider Name (Legal Business Name): GRENE VISION GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E NINTH
WINFIELD KS
67156
US

IV. Provider business mailing address

1851 N WEBB RD ATTN FLR2
WICHITA KS
67206-3413
US

V. Phone/Fax

Practice location:
  • Phone: 620-221-0740
  • Fax: 620-221-0738
Mailing address:
  • Phone: 316-636-2010
  • Fax: 316-691-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SHERYL DAVENPORT
Title or Position: INSURANCE DEPARTMENT SUPERVISOR
Credential:
Phone: 316-858-3830