Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | IL |
NPI | 1447294483 |
---|---|
Provider Name | Benjamin Leroy Light |
First Address | Peoria, IL 61614-8508 |
Second Address | Peoria, IL 61614-8508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 09/05/2008 |