Healthcare Provider Details

I. General information

NPI: 1558321208
Provider Name (Legal Business Name): MARY ALYSTER GRANT O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2006
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 E DESERT INN RD #700
LAS VEGAS NV
89121-3690
US

IV. Provider business mailing address

2755 E DESERT INN RD STE 270
LAS VEGAS NV
89121-3690
US

V. Phone/Fax

Practice location:
  • Phone: 702-836-3600
  • Fax: 702-836-3606
Mailing address:
  • Phone: 702-836-3600
  • Fax: 702-836-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number385
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number385
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number385
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: