Organization
GRAND LAKE OPTICAL, LLC
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) 787-2121
(918) 787-6002
Mailing address
P.O. BOX 451627, GROVE, OK 74345
(918) 787-2121
(918) 787-6002
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200005980A
—
OK
Enumeration date
08/17/2006
Last updated
11/18/2010
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