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General NPI Number Information
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NPI Number | 1366616476
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Entity Type | Organization
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Legal Business Name | BRIAN R GROSS,MD,INC.
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Dates
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Enumeration Date | 04/18/2008
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Last Update Date | 04/18/2008
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Provider Practice Location Address
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Address Line | 25880 TOURNAMENT RD SUITE 109
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City | VALENCIA
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State | CA
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Zip | 91355-2349
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Country | US
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Telephone | 661-255-6622
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Fax | 661-255-6628
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Provider Business Mailing Address
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Address Line | 25880 TOURNAMENT RD SUITE 109
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City | VALENCIA
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State | CA
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Zip | 91355-2349
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Country | US
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Telephone | 661-255-6622
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Fax | 661-255-6628
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Authorized Official
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Title or Position | OWNER/MD
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Name | DR. BRIAN RONALD GROSS
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Credential | MD
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Telephone | 661-255-6622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 156FX1100X
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License Number State | CA
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