Provider Demographics
NPI:1437476868
Name:GRANT, ECCLESIA LUCIANA (LDO)
Entity Type:Individual
Prefix:MRS
First Name:ECCLESIA
Middle Name:LUCIANA
Last Name:GRANT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:MRS
Other - First Name:ECCLESIA
Other - Middle Name:LUCIANA
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LDO
Mailing Address - Street 1:165 HIDDEN BROOK CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4440
Mailing Address - Country:US
Mailing Address - Phone:404-432-1772
Mailing Address - Fax:404-890-5574
Practice Address - Street 1:5534 OLD NATIONAL HWY
Practice Address - Street 2:SUITES 100-B
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3212
Practice Address - Country:US
Practice Address - Phone:404-432-1772
Practice Address - Fax:404-890-5574
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-25
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO 002273156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician