Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FC0800X | Contact Lens |
NPI | 1770906430 |
---|---|
Provider Name | Chaka Otey |
First Address | Quinton, VA 23141-2406 |
Second Address | Quinton, VA 23141 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2014 |
Last Update Date | 30/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
127006018017 | (05) | VA |