Provider Demographics
NPI:1548301690
Name:GRAND LAKE EYECARE LLC
Entity type:Organization
Organization Name:GRAND LAKE EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANDKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-586-3151
Mailing Address - Street 1:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-0377
Mailing Address - Country:US
Mailing Address - Phone:419-586-3151
Mailing Address - Fax:419-586-1059
Practice Address - Street 1:1025 GRAND LAKE RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1309
Practice Address - Country:US
Practice Address - Phone:419-586-3151
Practice Address - Fax:419-586-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5661870001Medicare NSC
OH9349941Medicare PIN