Healthcare Provider Details

I. General information

NPI: 1083344956
Provider Name (Legal Business Name): ALEXIS GRYCKO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7706 WINCHESTER RD
MEMPHIS TN
38125-2399
US

IV. Provider business mailing address

9691 WOLF RIVER BLVD
GERMANTOWN TN
38139-5537
US

V. Phone/Fax

Practice location:
  • Phone: 901-752-1551
  • Fax:
Mailing address:
  • Phone: 513-340-5872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3750
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: