Provider Demographics
NPI:1700117876
Name:GRAHAM, JEROME (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7351
Mailing Address - Country:US
Mailing Address - Phone:252-412-4679
Mailing Address - Fax:252-822-0044
Practice Address - Street 1:3743 OLD RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7351
Practice Address - Country:US
Practice Address - Phone:252-412-4679
Practice Address - Fax:252-822-0044
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1821156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician