Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0618000112 | VA |
NPI | 1003868829 |
---|---|
Provider Name | Dr. Christopher John Renner |
First Address | Baileys Crossroads, VA 22041-2872 |
Second Address | Baileys Crossroads, VA 22041-2872 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 21/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T31275 | (02) | |
VA009206531 | (05) | VA |