Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 000272 | AZ |
NPI | 1205462090 |
---|---|
Provider Name | John Le Roy Mellinger |
First Address | Monrovia, CA 91016-2813 |
Second Address | Monrovia, CA 91016-2813 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2020 |
Last Update Date | 12/03/2020 |