Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 941 | NC |
NPI | 1023290046 |
---|---|
Provider Name | Gary Lee Vaughn |
First Address | Indian Trail, NC 28079 |
Second Address | Indian Trail, NC 28079 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2007 |
Last Update Date | 30/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8802087 | (05) | NC |