Provider Demographics
NPI:1629590864
Name:DEVITO, GRECHIA STANLEY (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GRECHIA
Middle Name:STANLEY
Last Name:DEVITO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 SIERRAS LOOP
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-9046
Mailing Address - Country:US
Mailing Address - Phone:803-254-9381
Mailing Address - Fax:
Practice Address - Street 1:411 COMMERCE DR NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4583
Practice Address - Country:US
Practice Address - Phone:803-254-9381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000682156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000682OtherLICENSED DISPENSING OPTICIAN