Provider Demographics
NPI:1437857067
Name:GRUMELOT, MARY R
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
Last Name:GRUMELOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 HAVEMANN RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-9300
Mailing Address - Country:US
Mailing Address - Phone:419-584-0615
Mailing Address - Fax:419-584-0637
Practice Address - Street 1:1950 HAVEMANN RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-9300
Practice Address - Country:US
Practice Address - Phone:419-584-0615
Practice Address - Fax:419-584-0637
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017212-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician