Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1800X | Optician | D70604 | CA |
Y | 156FX1800X | Optician | SL40306 | CA |
NPI | 1164889424 |
---|---|
Provider Name | Miss Tierra Ilicia Leigh Grubbs |
First Address | Costa Mesa, CA 92626-7169 |
Second Address | Costa Mesa, CA 92626-7169 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2016 |
Last Update Date | 18/01/2016 |