MEDICARE: BRADLEY G GRUVER & KENNETH L KOCH PTRS

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1356412605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY G GRUVER & KENNETH L KOCH PTRS

Provider Business Mailing Address
First Line	:	124 E ROWAN AVE
Second Line	:	SUITE 101
City	:	SPOKANE
State	:	WA
Zip	:	99207-1214
Country	:	US
Telephone Number	:	509-487-5456
Fax Number	:	509-484-0082

Provider Business Practice Location Address
First Line	:	124 E ROWAN AVE
Second Line	:	SUITE 101
City	:	SPOKANE
State	:	WA
Zip	:	99207-1214
Country	:	US
Telephone Number	:	509-487-5456
Fax Number	:	509-484-0082

Authorized Official
Title or Position	:	PARTNER
Name	:	KENNETH LYLE KOCH
Credential	:	OD
Telephone Number	:	509-487-5456

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	12/03/2010

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