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General NPI Number Information
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NPI Number | 1891739066
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Entity Type | Individual
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Provider Name | TY M GRADEN OD
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Gender | Male
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Dates
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Enumeration Date | 06/16/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 405 S MARKET ST PRIMARY EYE CARE CENTER PC
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City | ELIZABETHTOWN
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State | PA
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Zip | 17022
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Country | US
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Telephone | 717-367-1883
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Fax | 717-367-1884
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Provider Business Mailing Address
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Address Line | 405 S MARKET ST PRIMARY EYE CARE CENTER PC
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City | ELIZABETHTOWN
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State | PA
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Zip | 17022
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Country | US
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Telephone | 717-367-1883
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Fax | 717-367-1884
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG001522
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License Number State | PA
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