Provider Demographics
NPI:1023748985
Name:GROSSHEIM, DIANE (ABOC,NCLE,LDO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GROSSHEIM
Suffix:
Gender:F
Credentials:ABOC,NCLE,LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 W DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2069
Mailing Address - Country:US
Mailing Address - Phone:803-425-9896
Mailing Address - Fax:803-425-8169
Practice Address - Street 1:2240 W DEKALB ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2069
Practice Address - Country:US
Practice Address - Phone:803-425-9896
Practice Address - Fax:803-425-8169
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1030156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician