Healthcare Provider Details

I. General information

NPI: 1710161716
Provider Name (Legal Business Name): ROBERT JOSEPH GRUCHALA FNAO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 CHIPPEWA
SAINT LOUIS MO
63109-2238
US

IV. Provider business mailing address

6200 CHIPPEWA ST
SAINT LOUIS MO
63109-2115
US

V. Phone/Fax

Practice location:
  • Phone: 314-352-6100
  • Fax: 314-752-3404
Mailing address:
  • Phone: 314-352-6100
  • Fax: 314-752-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number11078022
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: