Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 0396 | KY |
NPI | 1063563104 |
---|---|
Provider Name | Irving Peck |
First Address | Maysville, KY 41056 |
Second Address | Maysville, KY 41056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 10/12/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000077313 | BCBS (01) | KY |
0559408 | (05) | OH |
52800976 | (05) | KY |
52903960 | (05) | KY |