Provider Demographics
NPI:1043066798
Name:RIVERA, GRACE LISETTE (LDO)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LISETTE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:LISETTE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO
Mailing Address - Street 1:351 ALABAMA RD
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-3818
Mailing Address - Country:US
Mailing Address - Phone:229-896-9994
Mailing Address - Fax:229-896-9996
Practice Address - Street 1:351 ALABAMA RD
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-3818
Practice Address - Country:US
Practice Address - Phone:229-896-9994
Practice Address - Fax:229-896-9996
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002857156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician