=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417260340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN MARIE GRUBB O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2010
-----------------------------------------------------
Last Update Date | 09/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 STERLING WAY SUITE C
-----------------------------------------------------
City | MT STERLING
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40353-1174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-498-4800
-----------------------------------------------------
Fax | 859-498-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 STERLING WAY SUITE C
-----------------------------------------------------
City | MT STERLING
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40353-1174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-498-4800
-----------------------------------------------------
Fax | 859-498-2021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1807DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------