Provider Demographics
NPI:1073663068
Name:NER, GRACIE (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:GRACIE
Middle Name:
Last Name:NER
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13775 GLENOAKS BLVD UNIT 30
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-8370
Mailing Address - Country:US
Mailing Address - Phone:818-364-9052
Mailing Address - Fax:
Practice Address - Street 1:2941 COCHRAN ST STE 5
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2789
Practice Address - Country:US
Practice Address - Phone:805-583-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10773T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107730Medicaid