Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1114976420 |
---|---|
Provider Name | Charda P Bronaugh |
First Address | Lufkin, TX 75904-3103 |
Second Address | Lufkin, TX 75904-3103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2006 |
Last Update Date | 15/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
086517201 | (05) | TX |
27897 | (02) | TX |
4007229 | (02) | TX |
506834 | (02) | TX |
925010 | (02) | TX |
OP1740 | (02) | TX |