Healthcare Provider Details

I. General information

NPI: 1548778160
Provider Name (Legal Business Name): DARRELL E GROMAN OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HILTY DRIVE
PANDORA OH
45877-0209
US

IV. Provider business mailing address

204 HILTY DRIVE P.O. BOX 209
PANDORA OH
45877-0209
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-3275
  • Fax: 419-384-3285
Mailing address:
  • Phone: 419-384-3275
  • Fax: 419-384-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DARRELL EUGENE GROMAN
Title or Position: SOLE OWNER
Credential:
Phone: 419-384-3275