Provider Demographics
NPI:1871110783
Name:ANDERSON, GRACE (OD, MS)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 NE WEST DEVILS LAKE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-5195
Mailing Address - Country:US
Mailing Address - Phone:541-614-0946
Mailing Address - Fax:
Practice Address - Street 1:2715 WILLETTA ST SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3471
Practice Address - Country:US
Practice Address - Phone:208-392-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist