Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 41111 | CA |
NPI | 1164060398 |
---|---|
Provider Name | Amber Diaz |
First Address | Austin, TX 78753-2658 |
Second Address | Burbank, CA 91506-2150 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2019 |
Last Update Date | 18/12/2019 |