Provider Demographics
NPI:1497587596
Name:CAPPS, TRACEY LYNN (LDO)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:CAPPS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4562 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:SC
Mailing Address - Zip Code:29541-3820
Mailing Address - Country:US
Mailing Address - Phone:843-687-5127
Mailing Address - Fax:
Practice Address - Street 1:900 US 52 HWY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-5906
Practice Address - Country:US
Practice Address - Phone:843-394-7626
Practice Address - Fax:843-394-8052
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1440156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty