Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 110000 | KY |
NPI | 1043891013 |
---|---|
Provider Name | Anthony Elvis Brewster |
First Address | Louisville, KY 40207-4704 |
Second Address | Louisville, KY 40207-4704 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2021 |
Last Update Date | 20/04/2021 |