Basic Information
| Provider Information | |||||||||
| NPI: | 1821200478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRENE VISION GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1851 N WEBB RD | ||||||||
| Address2: | ATTN FLR2 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166362010 | ||||||||
| FaxNumber: | 3166914408 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WEST 29TH ST | ||||||||
| Address2: | STE C | ||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202351737 | ||||||||
| FaxNumber: | 6202300358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 02/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | SHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE DEPARTMENT SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3168583831 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.