Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1101X | Ophthalmic Assistant | ||
Y | 156FX1202X | Optometric Technician |
NPI | 1588970479 |
---|---|
Provider Name | Brianne Marie Luck |
First Address | Jefferson City, MO 65109-1002 |
Second Address | Jefferson City, MO 65109-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2010 |
Last Update Date | 30/08/2010 |