Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152WC0802X | Optomitrist - Corneal and Contact Lenses | OD00001150 | WA |
NPI | 1306882600 |
---|---|
Provider Name | Dr. Larry Leon Beach |
First Address | Renton, WA 98055-5738 |
Second Address | Renton, WA 98055-5738 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2025096 | (05) | WA |
T01974 | (02) | AL |