Healthcare Provider Details

I. General information

NPI: 1336079524
Provider Name (Legal Business Name): JACOB EARL GRUND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 7TH ST W
PARK RAPIDS MN
56470-1872
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-699-3121
  • Fax:
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4063
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: