Provider Demographics
NPI:1205288370
Name:GRICHINE, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GRICHINE
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 1:2414 S FAIRVIEW ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5318
Mailing Address - Country:US
Mailing Address - Phone:714-557-9492
Mailing Address - Fax:
Practice Address - Street 1:2414 S FAIRVIEW ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5318
Practice Address - Country:US
Practice Address - Phone:714-557-9492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33473TLG152W00000X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision