Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 354 | AZ |
NPI | 1134243009 |
---|---|
Provider Name | Kenn Rosek |
First Address | Peoria, AZ 85381-4836 |
Second Address | Peoria, AZ 85381-4836 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2007 |
Last Update Date | 08/07/2007 |