Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 4901004859 | MI |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 4901004859 | MI |
N | 152WP0200X | Pediatric Optomitrist | 4901004859 | MI |
NPI | 1336556893 |
---|---|
Provider Name | Dr. Tom Lavern Hall II |
First Address | Fowlerville, MI 48836-5136 |
Second Address | Fowlerville, MI 48836 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2014 |
Last Update Date | 08/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1336556893 | (05) | MI |