Provider Demographics
NPI:1881689263
Name:KLECKLEY, JULIANNE STUCK (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIANNE
Middle Name:STUCK
Last Name:KLECKLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 KNOX ABBOTT DR
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-4127
Mailing Address - Country:US
Mailing Address - Phone:803-794-4444
Mailing Address - Fax:803-794-2085
Practice Address - Street 1:600 KNOX ABBOTT DR
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-4127
Practice Address - Country:US
Practice Address - Phone:803-794-4444
Practice Address - Fax:803-794-2085
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC751152W00000X
MN2896152W00000X
GAOPT001033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD07516Medicaid
T23965Medicare UPIN