Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LDO002502 | GA |
NPI | 1093128050 |
---|---|
Provider Name | Alta M Lebeck |
First Address | Tifton, GA 31794-4813 |
Second Address | Tifton, GA 31794-4813 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2014 |
Last Update Date | 07/06/2014 |