Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1316300163 |
---|---|
Provider Name | Brandon Ray La Fuente |
First Address | Edmond, OK 73025-2832 |
Second Address | Edmond, OK 73025-2832 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2016 |
Last Update Date | 27/04/2017 |