MEDICARE: BRADLEY GENE GRUVER OD

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	0301979	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396828950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY GENE GRUVER OD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	10/11/2007

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Directions to “ BRADLEY GENE GRUVER OD” Practice Location

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