Provider Demographics
NPI:1306983655
Name:GRAND TETON EYE & OPTICAL
Entity type:Organization
Organization Name:GRAND TETON EYE & OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-787-2088
Mailing Address - Street 1:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0613
Mailing Address - Country:US
Mailing Address - Phone:208-787-2088
Mailing Address - Fax:
Practice Address - Street 1:110 BUFFALO WAY STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-8460
Practice Address - Country:US
Practice Address - Phone:307-733-4905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty