Basic Information
| Provider Information | |||||||||
| NPI: | 1427357763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEAGRAVES | ||||||||
| FirstName: | CANDACE | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4160 HERITAGE TRACE PKWY | ||||||||
| Address2: | STE. 400 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762445312 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4160 HERITAGE TRACE PKWY | ||||||||
| Address2: | STE. 400 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762445312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177412020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 7330TG | TX | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 5820/T2744 | OH | N | Eye and Vision Services Providers | Optometrist |
No ID Information.