=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881689263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIANNE STUCK KLECKLEY OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 KNOX ABBOTT DR
-----------------------------------------------------
City | CAYCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29033-4127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-794-4444
-----------------------------------------------------
Fax | 803-794-2085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 KNOX ABBOTT DR
-----------------------------------------------------
City | CAYCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29033-4127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-794-4444
-----------------------------------------------------
Fax | 803-794-2085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 751
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2896
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT001033
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------