Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 001672 | CT |
NPI | 1063750396 |
---|---|
Provider Name | Jessica Rivera |
First Address | Wellesley, MA 02482-3744 |
Second Address | Middletown, CT 06457-3396 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2013 |
Last Update Date | 24/10/2014 |