Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SL6061 | CA |
NPI | 1215261425 |
---|---|
Provider Name | Dana S Russell |
First Address | Clovis, CA 93612-0311 |
Second Address | Clovis, CA 93612-0311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2009 |
Last Update Date | 22/09/2009 |