MEDICARE: GRO OPTICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1336849074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRO OPTICAL, LLC

Provider Business Mailing Address
First Line	:	511 WILSON AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7986
Country	:	US
Telephone Number	:	616-301-8663
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 WILSON AVE NW STE E
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7986
Country	:	US
Telephone Number	:	616-301-8663
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DAVID CLARK
Credential	:
Telephone Number	:	636-227-2600

Provider Enumeration Date	:	03/09/2023
Last Update Date	:	04/10/2023

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