Provider Demographics
NPI:1346973609
Name:DECASTRO, SENECA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:SENECA
Middle Name:
Last Name:DECASTRO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 892
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-0892
Mailing Address - Country:US
Mailing Address - Phone:727-204-6791
Mailing Address - Fax:
Practice Address - Street 1:WALMART VISION CENTER
Practice Address - Street 2:1180 DUTCH FORK RD
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-740-2635
Practice Address - Fax:803-781-6324
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1286156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician