Healthcare Provider Details

I. General information

NPI: 1629248448
Provider Name (Legal Business Name): MAVES EYEWEAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S COLUMBIA RD
GRAND FORKS ND
58201-4055
US

IV. Provider business mailing address

1101 S COLUMBIA RD
GRAND FORKS ND
58201-4055
US

V. Phone/Fax

Practice location:
  • Phone: 701-775-4114
  • Fax:
Mailing address:
  • Phone: 701-775-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number458
License Number StateND

VIII. Authorized Official

Name: DR. STEVEN P GANDER
Title or Position: PRESIDENT
Credential: OD
Phone: 218-773-3438