Basic Information
| Provider Information | |||||||||
| NPI: | 1255060588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | LANGLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 BYPASS 25 NE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643216030 | ||||||||
| FaxNumber: | 8642239706 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BYPASS 25 NE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643216030 | ||||||||
| FaxNumber: | 8642239706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2022 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 1311 | SC | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.