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General NPI Number Information
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NPI Number | 1184684011
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Entity Type | Organization
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Legal Business Name | GRAND LAKE IMAGING PC
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Dates
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Enumeration Date | 03/24/2006
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Last Update Date | 03/30/2023
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Provider Practice Location Address
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Address Line | 1001 E 18TH ST
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City | GROVE
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State | OK
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Zip | 74344-2907
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Country | US
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Telephone | 918-221-7506
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2264
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City | INDIANAPOLIS
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State | IN
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Zip | 46206-2264
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Country | US
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Telephone | 918-221-7506
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEVIN JAMES YUNT
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Credential | D.O.
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Telephone | 918-221-7506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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