Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 008025-1 | NY |
NPI | 1124350228 |
---|---|
Provider Name | Jeremy Beck |
First Address | Moriches, NY 11955-1425 |
Second Address | Moriches, NY 11955-1425 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2010 |
Last Update Date | 01/02/2010 |