Healthcare Provider Details

I. General information

NPI: 1124653209
Provider Name (Legal Business Name): GRO OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-6049
US

IV. Provider business mailing address

4020 E BELTLINE AVE NE STE 201
GRAND RAPIDS MI
49525-9324
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-1350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KELLY THERRIEN
Title or Position: OPTICAL BILLING SYSTEMS MANAGER
Credential:
Phone: 616-588-6532