Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LDO2544 | GA |
NPI | 1225681794 |
---|---|
Provider Name | Bruce Eric Kennedy |
First Address | Adel, GA 31620-3818 |
Second Address | Adel, GA 31620-3818 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2019 |
Last Update Date | 23/07/2019 |