NPIMap

Organization Active NPI

Grand Lake Optical, LLC

  • Eyewear Supplier
  • Grove, OK
National Provider Identifier
1649383191
Registry record updated Nov 18, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
GRAND LAKE OPTICAL, LLC
Practice address
1120 Neo Loop
Grove, OK 74344
Phone
(918) 787-2121
Fax
(918) 787-6002
NPI assigned
Aug 17, 2006
Last updated
Nov 18, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 18, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kevin K Toller, MDNPI 1457373466
Title
President
Phone
(918) 787-2020

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X NU Primary

Addresses

Primary practice location

1120 Neo Loop
Grove, OK 74344

Mailing address

P.O. Box 451627
Grove, OK 74345
Phone (918) 787-2121

Other identifiers 1

IdentifierTypeStateIssuer
200005980AMedicaidOK

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155772800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1290038400000",
    "number": "1649383191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 451627",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "74345",
            "telephone_number": "918-787-2121",
            "fax_number": "918-787-6002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1120 NEO LOOP",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "74344",
            "telephone_number": "918-787-2121",
            "fax_number": "918-787-6002"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND LAKE OPTICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-17",
        "last_updated": "2010-11-18",
        "status": "A",
        "authorized_official_last_name": "TOLLER",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "918-787-2020",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200005980A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grove, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.