=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073663068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACIE NER OPTOMETRIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2941 COCHRAN ST STE 5
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93065-2789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-583-3028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13775 GLENOAKS BLVD UNIT 30
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-8370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-364-9052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10773T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------