Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 632 | CT |
NPI | 1023245776 |
---|---|
Provider Name | Mr. Bradley Peter Bohman |
First Address | Westerly, RI 02891-1741 |
Second Address | Waterford, CT 06385 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2009 |
Last Update Date | 19/06/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
581910859 | TAX ID (01) | CT |