Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XL0004X | Low Vision | OT006081 | GA |
NPI | 1417354259 |
---|---|
Provider Name | Mary Gower |
First Address | Atlanta, GA 30044-1137 |
Second Address | Atlanta, GA 30308-1137 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2014 |
Last Update Date | 21/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1497893671 | MEDICARE GRP7122 (01) | GA |
58-1168874 | 58-1168874 (01) | GA |