Provider Demographics
NPI:1780093716
Name:GRO OPTICAL, LLC
Entity type:Organization
Organization Name:GRO OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-227-2600
Mailing Address - Street 1:6050 NORTHLAND DR NE
Mailing Address - Street 2:STE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9244
Mailing Address - Country:US
Mailing Address - Phone:616-588-6582
Mailing Address - Fax:
Practice Address - Street 1:6050 NORTHLAND DR NE
Practice Address - Street 2:STE 100
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9244
Practice Address - Country:US
Practice Address - Phone:616-588-6582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0269810012Medicare NSC