Healthcare Provider Details

I. General information

NPI: 1639008485
Provider Name (Legal Business Name): GRACE E YUSTIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5280 FL-100 SUITE 101
PALM COAST FL
32164
US

IV. Provider business mailing address

5280 FL-100 SUITE 101
PALM COAST FL
32164
US

V. Phone/Fax

Practice location:
  • Phone: 386-313-7537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6947
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: