Organization
GRAND LAKE EYE CARE, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEVIN K TOLLER MD (PRESIDENT)
(918) 787-2020
Entity
Organization
Contact information
Practice address
1120 NEO LOOP, GROVE, OK 74344
(918) 787-2020
(918) 787-6002
Mailing address
PO BOX 450400, GROVE, OK 74345
(918) 787-2020
(918) 787-6002
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
21196
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100138230A
—
OK
01
—
180037253
RAILROAD MEDICARE
OK
05
—
200216660A
—
OK
Enumeration date
02/26/2007
Last updated
11/18/2010
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