Healthcare Provider Details

I. General information

NPI: 1407038417
Provider Name (Legal Business Name): GROVE EYE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 S MAIN ST
GROVE OK
74344-2847
US

IV. Provider business mailing address

PO BOX 452529
GROVE OK
74345-2529
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-9777
  • Fax: 918-786-8458
Mailing address:
  • Phone: 918-786-9777
  • Fax: 918-786-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number970
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2608
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number970
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2608
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number970
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2608
License Number StateOK
# 7
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number970
License Number StateOK
# 8
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2608
License Number StateOK
# 9
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number970
License Number StateOK
# 10
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2608
License Number StateOK
# 11
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number970
License Number StateOK
# 12
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2608
License Number StateOK
# 13
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number970
License Number StateOK
# 14
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2608
License Number StateOK

VIII. Authorized Official

Name: BURNESS R YANDELL
Title or Position: PRESIDENT
Credential: OD
Phone: 918-786-9777