Provider Demographics
NPI:1316395775
Name:GRANT OPTOMETRIC GROUP INC.
Entity type:Organization
Organization Name:GRANT OPTOMETRIC GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-557-2020
Mailing Address - Street 1:3140 BEAR ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3140 BEAR ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2964
Practice Address - Country:US
Practice Address - Phone:714-557-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty