Healthcare Provider Details

I. General information

NPI: 1548301690
Provider Name (Legal Business Name): GRAND LAKE EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 GRAND LAKE RD
CELINA OH
45822-1309
US

IV. Provider business mailing address

PO BOX 377
CELINA OH
45822-0377
US

V. Phone/Fax

Practice location:
  • Phone: 419-586-3151
  • Fax: 419-586-1059
Mailing address:
  • Phone: 419-586-3151
  • Fax: 419-586-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH J SANDKER
Title or Position: PARTNER
Credential: OD
Phone: 419-586-3151