Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 81465 | TN |
NPI | 1093862005 |
---|---|
Provider Name | Bobby Gene Luttrell |
First Address | Knoxville, TN 37919-4702 |
Second Address | Knoxville, TN 37919-5187 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4094205 | BLUE CROSS BLUE SHIELD NU (01) | TN |