Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 006131-01 | NY |
NPI | 1093380768 |
---|---|
Provider Name | Michelle L Damico |
First Address | Bergen, NY 14416-9350 |
Second Address | Brockport, NY 14420-1118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2021 |
Last Update Date | 25/05/2021 |