=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497805451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE M WILEY O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 03/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR.172 DE CAGUAS A CIDRA ; URB. TURABO GARDENS PRIMER PISO, HOSPTAL MENONITA CAGUAS
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-637-0834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 CALLE SAN JULIAN URB SAGRADO CORAZON
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-4243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-637-0834
-----------------------------------------------------
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 | 464
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------