Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FC0800X | Contact Lens | DO 3084 | FL |
NPI | 1790999134 |
---|---|
Provider Name | Freddie Lovell |
First Address | Plantation, FL 33317-3100 |
Second Address | Plantation, FL 33317-3100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 21/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
630184300 | (05) | FL |