Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4263 | MA |
NPI | 1164822516 |
---|---|
Provider Name | Kevin Diaz |
First Address | Beverly, MA 01915-1168 |
Second Address | Beverly, MA 01915-1168 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2014 |
Last Update Date | 03/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
156FX18004 | (05) | MA |