Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SLD5882 | CA |
NPI | 1023620648 |
---|---|
Provider Name | Blanca Estela Maldonado |
First Address | Loma Linda, CA 92354-1708 |
Second Address | Colton, CA 92324-4014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2020 |
Last Update Date | 17/08/2020 |