Healthcare Provider Details

I. General information

NPI: 1033182936
Provider Name (Legal Business Name): ROYCE L. GRIMSRUD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E MAPLE ST
SISSETON SD
57262-1412
US

IV. Provider business mailing address

PO BOX 149
SISSETON SD
57262-0149
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-4112
  • Fax: 605-698-3160
Mailing address:
  • Phone: 605-698-4112
  • Fax: 605-698-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number437
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: