Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1093921579 |
---|---|
Provider Name | Brian Scott |
First Address | Deerfield, IL 60015-4993 |
Second Address | Deerfield, IL 60015-4993 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2007 |
Last Update Date | 08/07/2007 |