Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 4001 | AR |
NPI | 1003977364 |
---|---|
Provider Name | Glynn Griffin |
First Address | Rogers, AR 72758-8323 |
Second Address | Rogers, AR 72758-8323 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 31/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T19560 | (02) | LA |