Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1101X | Ophthalmic Assistant | D3159 | NJ |
Y | 156FX1800X | Optician | D3159 | NJ |
NPI | 1124292057 |
---|---|
Provider Name | Christian John Kubick |
First Address | Millburn, NJ 07041-1326 |
Second Address | Millburn, NJ 07041-1326 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2008 |
Last Update Date | 22/04/2008 |