Provider Demographics
NPI:1437804457
Name:DIEDE, ALECIA MARIE
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:MARIE
Last Name:DIEDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:503-352-2020
Mailing Address - Fax:
Practice Address - Street 1:3101 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3162
Practice Address - Country:US
Practice Address - Phone:605-361-3937
Practice Address - Fax:605-371-7199
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist