Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1605 | CT |
NPI | 1154779379 |
---|---|
Provider Name | Justine Burdick |
First Address | Norwich, CT 06360-6455 |
Second Address | Norwich, CT 06360-6455 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2016 |
Last Update Date | 27/05/2016 |